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6 6 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: Wr 'E' �� - L/� :� 1. Chemicals Hazards <br /> Address: !4'6_ [1 Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number. ❑Dusts: <br /> Proposed Date of investigation/inspection: Cl Explosives: <br /> ❑Flemmables: <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 /> '91 H t.-J r f— PART III <br /> 3. Specific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Conten[: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> + + p ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: <br /> �QJf�.I, J�.S Cr ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Otherspecify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES [I NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment �y <br /> Level of Protection: ❑A C1 C]C +13 <br /> 6. Potential Health and Safety }lard Hat <br /> Physical Concerns:(check all that apply&describe) .QSafety 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: 54:11earing protection. <br /> ❑Excavation:(falls,nips,slipping,cave-ins): ❑Tyvek. <br /> Handling and Transfer of a Hazardous Substance:(fire,explosions, C]Respirator: C]APR ❑SCBA <br /> etc..): <br /> A/P cartridge: <br /> ❑Confined space entry:(explosions): <br /> ❑Heavy equipment(physical injury&[mama resulting from moving <br /> Safety vest. <br /> equipment): Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑ Insects ❑Rodents ❑Poisonous Plants Plan Prepared Date: V <br /> C]Other/Unlmown(specify): <br /> Plan Approved 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 />