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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:Pilkington I. Chemicals Hazards <br /> Address:500 E Louise Ave Lathrop �Carcinogens: <br /> Contact Person:Roger Bishop Phone No: ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> ❑Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> New UST installation. ❑Inorganic Gases: <br /> ❑ ❑UAR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> V PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> Hazardous Waste Inspection <br /> 3. Specific Site Information: PART III <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: <br /> operations unless appropriate rationale or restrictions we provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:Glass manufacturer ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑mer'specify' <br /> Documented Groundwater contamination: <br /> ❑YES ❑NO If monitoring instruments we 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 Level of Protection: ❑A ❑B ❑C ❑ D <br /> Hard Hat. <br /> Physical Concerns:(check all that apply&describe) q Safety Glasses/goggles. <br /> Heat or Cold Stress: °F(high ambient temp.) <br /> J Steel toed/shank shoes or hoots. <br /> Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> eta.): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> q Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous PlantsPrepared by: <br /> fY) <br /> ( P : <br /> 3 <br /> ❑Other/Unknown s eci Plan Date: <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />