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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMt4T1 n)NG EVALUATION OF POTENTIp�/HAZARDS <br /> (�J r`V <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: J ,tomCu <br /> Contact Person:_ /,Pa _ _Phone No: J � ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> blas: 0 <br /> 2. Description and brief narrative of inspection activity: coa�Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> ,(// [�� ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: (,_l b �✓C.!"w✓ ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: <br /> ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: YES NO <br /> ❑ ❑If monitoring insOthtruments <br /> specify. us <br /> El YES are not ed,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ❑D <br /> Physical Concerns:(check all that apply&describe) A Hard <br /> Hat <br /> ,PdHem or Cold Stress: OF(high ambient temp.) %8afety Glasses/goggles. <br /> -Steel toed/shank shoes or boots. <br /> C3 Noise Sources: 111�Fearing protection.lame retardant coveralls. <br /> [3 Oxygen Deficiency: <br /> H <br /> ❑ <br /> Excavation:(falls,trips,slipping,rave-ins): <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> eta.): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): E14aaOsvay communication. <br /> ❑Other.specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> J�$palres scats ❑Poisonous Plants <br /> ❑Other/Un(mown s err Plan Prepared by: Date: <br /> Plan Approved by: 1` Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, y� <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />