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4t <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: I. Chemicals Hazards <br /> Address: <br /> ❑Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: cagw <br /> ElDusts: <br /> Proposed Date of investigation/inspection: 7Woa ❑Explosives: <br /> ElFlammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> F1New UST installation. ElUAR Investigation. ElMetals: <br /> r_1Tank Closure in Place. ElTank/Pipe Repair. EIOxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑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: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: - Q M� 7y ta ivia EJ Detector Tubes(Specify). <br /> 14 El ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: [I YES [:1NO El Other,specify. <br /> Documented Groundwater contamination: ❑YES F-1 NO I f monitoring instruments are not used,rationale or activity/area restrictions: <br /> Ba kand description of any previous investigation or incidence: <br /> x fi- e-'0116121 }4_411L <br /> 1 ' 02. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ❑D <br /> Physical Concerns:(check all that apply&describe) ❑Hard Hat. <br /> ❑Hear or Cold Stress: IF(high ambient temp.) [:1 Safety Glasses/goggles. <br /> E]Steel toed/shank shoes or boots. <br /> El Noise Sources: <br /> E]Flame retardant coveralls. <br /> El Oxygen Deficiency: <br /> ❑Excavation:(falls,trips,slipping,cave-ins): El Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, [3 Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <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 /> El Snakes El Insects El Rodents El Poisonous Plants Plan Prepared by: at "mate: { (� <br /> ❑Other/Unknown(specify): <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 />