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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SIT I iF RMA ONN r^-�"�--a-""'—�— EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: s 1. fChhemicals Hazards .,a,,� <br /> Address: (� w �. �gCarcinogens: /NY{1 of l <br /> Contact Person: � r:-.4444N Phone No: 9%89Y11- <br /> ❑Corrosives: <br /> Sweeps Number: obusts: <br /> Proposed Date of investigation/inspection: 't7'� ❑Explosives: <br /> '®Flenunables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> C Oi t'ejtn o_VIoan i PART III <br /> 3. peri¢Sile Infomra[ion: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Contain Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> E]Combustible Gas/Oxygen Meta. <br /> 4. Type of Operation: �-�C.J �vP"r"� ❑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: <br /> ❑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 Prolective 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) �Safety Glasses/goggles. <br /> El Hear or Cold Stress: OF(high ambient tamp.) <br /> Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> 29 Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> E]Heavy p <br /> Heavy equipment(physical injury&trauma resulting from moving w Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: �y �/ / <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants `w ���I ( � <br /> E]Other/Unknown(specify): Plan Prepared by: 1'l Date: II rr <br /> Plan Approved by: IIyNV, Dale: <br /> 8. Nanative(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 />