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SITE HEALTH AND SAFETY PLAN <br /> PART I / PART II <br /> GENERAL SITE INT TION �, /)� . ' A���I►/ EVALUATION OF POTENTIAL HAZARDS <br /> Chm1. Site Name: �� I`��, I �l/( <br /> ' Is Hazards <br /> Address: _ / <br /> 7u n. ®Carcinogens: <br /> Contact Person:_ 1JM Phone No: n..__ <br /> r--�---r-1-�— - ��. ,— �Corrosives: <br /> Sweeps Number: Q ❑Dusts: <br /> Proposed Date of investigation/inspectiom- ❑ <br /> losrvea <br /> IF <br /> bies: o" soil-fillel'f—IWVM ==A--,A � <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. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells, <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: TeAge: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: / operations unless appropriate rationale or restrictions are provided) <br /> W — ❑Combustible Gas/Oxygen Meter. <br /> 5, <br /> ' 12 f 't, � ❑Detector Tubes(Specify). <br /> 4. Type of Operation: .�--L�6 Q (-- <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑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 /> 6, Potential Health and Safety Level of Protection: ❑A ❑B ❑C ®D <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> ❑Hear or Cold Stress: IF(high ambient temp.) ®Safety Glasses/goggles. <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation: falls,trips,slipping,cave-ins): ®Hearing protection. <br /> ( <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 /> ❑Heavy equipment(physical injury&trauma resulting from moving ®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 <br /> Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: U W 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 />