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SITE HEALTH AND SAFETY PLAN <br />PARTI <br />PARTE[ <br />GENERAL SITE INFORMATI N <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: IN <br />^t a meals Hazards <br />Address: 11 <br />�1 <br />/f' I ® Carcinogens: <br />Contact Person: „y_Ehone No: <br />''a4VV <br />—`(YZ3 EJCorrosives: <br />Sweeps Number: <br />I Duals.13 <br />/Lo' <br />Proposed Date of investigation/inspection: _ <br />(/ losives: P <br />lammables: oil filters. solvents <br />2. Description and brief narrative of inspection activity: <br />El Inorganic Gases: <br />❑ New UST installation. ❑ UAR Investigation. <br />❑ Metals: ' <br />❑ Tank Closure in Place. ❑ Tank(Pipe Repair. <br />❑ Oxidizers: <br />❑ Tank/Pipe Removal. ❑ R"xcavation. <br />❑ PCB's: <br />❑ Installation of Borings / Monitoring Wells. <br />Specific Site Information: <br />Tank 1, - 3 <br />T�plc Capacity: <br />Tank Conten <br />k Age: <br />Other: <br />_ / L <br />�/i;0 J l <br />Type of Operation l <br />L CV <br />Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />& Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />Mr 1 <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />enrl <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <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 />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR <br />A/P cartridge: <br />® Safety vest. <br />❑ Two-way communication. <br />❑ SCBA <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: Jeffrey Wong Date: %W / <br />Plan Approved by: Date: <br />