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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO ATIO EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: Is Hazards <br /> Address: —<.4k�f 0. �//®Carcinogens: <br /> Contact Person: Phone No: //({,/�L�J,Corrosives: <br /> Sweeps Number: <br /> yL/` ❑Dusts: <br /> Proposed Date of investigation/inspection:_ /'�•` Explosives: <br /> to /iv/' ' ables: oil filterssolvents <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. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Informatio ART In <br /> Tank No.:IV,�Tank Capacity: �C IGi` 1Z REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content f ' '� ank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other. GJ _/ , operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: �� ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: ❑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 /> Level of Protection: [IA ElB El ®D <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> F7Hear or Cold Stress: OF(high ambient temp.) ®Safety Glasses/goggles. <br /> ®Steel toed shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Oxygen Deficiency: I—]Flamer coveralls. <br /> ®Hearingg protection.ion. <br /> ❑ Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> Respirator: ❑APR ❑SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑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 E]Poisonous Plants Plan Prepared by: Jeffrey Wong <br /> ❑OtherNnlmown(specify): <br /> Plan Approved by: U � 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(12/172002) <br />