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a 0 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I FART II <br /> GENERAL SITE INFORMAT N7^ _,(f + EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 7 r F�l/�"��w� J 1. Chemicals Hazards <br /> Address: 2110 /C3 Carcinogens: _ <br /> Contact Person: Phone No: ®Corrosives: <br /> Sweeps Number: -;n Dusts: <br /> Proposed Date of investigation/inspection: ` <br /> Po3 � � r 1 -- ,e,Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑ Inorganic Gases: <br /> ❑New UST installation. Q UAR Investigation. Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. yd ifS � ❑PCB's: <br /> Installation of Borings I Monitoring e ftS ��v+ <br /> 3. Specific Site Information: PART TII <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 /> 011ier: <br /> operations unless appropriate rationale or restrictions are provided) <br /> +_ _ El Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:�M& 4 ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks I soil contamination: <br /> ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: ❑YES NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> ❑ <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> & Potential Health and Safety Level of Protection: ❑A ❑ B ❑C ❑ D <br /> Physical Concerns:(check all that apply&describe) ❑Hard Hat. <br /> F1Hear or Cold Stress: °F(high ambient temp.) Safety Glasses/goggles. <br /> F1 Noise Sources: Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> Excavation: falls,tris slipping,cave-ins ❑Hearing protection. <br /> ElHandling and Transfer of a Hazardous Substance:(fire,explosions, [3 Tyvek. <br /> etc..): ❑Respirator. ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> Q Heavy equipment(physical injury&trauma resulting from moving qSafety vest. <br /> equipment): Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> -4 <br /> Snakes )]Insects El Rodents ElPoisonousPrepared by:Poisonous Plants A M 0-t- Date. <br /> ^^^��� <br /> ❑Other/Unknown(specify): } fj <br /> ��/� <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12J17/2002) <br />