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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORM Ipj)i '/ o� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: � w�w I. Ghemieals Hazards <br /> Address: _ Q ®Carcinogens: (� <br /> Contact Person: / �❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of invmtigation/u/�spection:_ ❑Explosives: <br /> liam nables: 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 /> PARTIH <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: <br /> Tank Age: 1. Monitoring Equipment(note:Monitoring instruments mus[ used for all <br /> Tank Content <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> /f,/� `/ ❑Detector Tubes(Specify) <br /> 4. Type of Operation: I' �� `� ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C OD <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) Z Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator. ❑APR ❑SCBA <br /> etc..): <br /> AM cartridge: <br /> ❑Confined space entry:(explosions): <br /> Safety vest. <br /> C1 Heavy equipment(physical injury&trauma resulting from moving <br /> ® <br /> ❑Two-way communication. <br /> equipment): <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: Jeffrey Wong Dare <br /> ❑Other/Unknown(specify): � t4 1 <br /> Plan Approved by: 1'--' Date: <br /> S. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,termin,etc.) <br /> EH 23081(12/17/2002) <br />