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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE IN ORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Naa 4f A 1, Chemicals Hazards.. __\\ rr � L�� �� ,,,A��11 <br /> Address: - y� � 9 Carcinogens: l� q I (.a1�O r""+`I <br /> Contact Person: UEE ?A . phone No: <br /> ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: "3 )Z ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 5 � %! e � PART III <br /> 3, pRmific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> /1/,/A/p <br /> El Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:�'`e^'r W ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contaminati n: [I YES <br /> ❑N ❑Other,specify. <br /> Documented Groundwater contaminatr n: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety <br /> Level of Protection: ❑A ❑B EIC <br /> Physical Concerns:(check all that apply&describe) EkJiard Hat. <br /> �easeor Cold Stress: °F(high ambient temp.) Safety Glasses/goggles. <br /> Noise Sources: Z Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cavo-ins): Hearing protection. <br /> E]Handling and Transfer of a Hazardous Substance:(fire,explosions, [I Tyvek. <br /> eta.): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving J6d Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: /J trt <br /> ❑Snakes Insects E]Rodents ❑Poisonous Plants <br /> ❑Other/U owns eci Plan Prepared by: Date: <br /> (P fY) ny ^ <br /> ` ✓1 12 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: U Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />