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0 41 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION /�/ EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: k6�gE La+� C-4-jr, 1. Chemicals Hazards <br /> Address: k f:721 f'7 <br /> ❑Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: / 2 —1— /.-7 11❑�,,Explosives: <br /> - 9—Flammables: <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 /> ❑r�Install,at//ion of Borings�/1M�onitoo ng Wells. <br /> ,15 n5�' t-1.5-66, (1Pw+�7�'v!- 5-7— MS` <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. 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: ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: [I YES [INO ❑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 C3B [IC IRD <br /> 6. Potential Health and Safety . <br /> ,�Hard Hat <br /> Physical Concerns:(check all that apply&describe) Safety Hat. <br /> El Hear or Cold Stress: IF(high ambient temp.) <br /> .10 Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ❑Hearing protection. <br /> Sa$xcavation:(falls,trips,slipping,caveins): <br /> C10 Handling and Transfer of a Hazardous Substance:(fire,Lplos— iRespirator: ❑APR C]SCBA <br /> arc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving Safety vest. <br /> equipment): IR7wo-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared b Date:. /y�1� <br /> E]Olher/Unlmown(specify): <br /> Plan Approved by: II L. 1�� Date: t' <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,Certain,etc.) <br /> EH 23081(12/17/2002) <br />