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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMA,IQN t, EVALUATION OF POTENTIAL H S <br /> 1. Site Name: (( r ' Is Hazards Y <br /> Address: t S E Carcinogens: <br /> Contact Person: 196 t f*one No:_ 1 v .corrosives: a4. 4 <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of invm6gation/inspection:- '2 ,..//❑,..,, Explosives: <br /> c�.Flaaunables: oil filters,solvents <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 /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> OiVer operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: (✓V l ❑Detector Tubes(Specify). <br /> 00 So '0 a!�J t�'!' ❑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 /> , - — -fiit5. S r ll `e �� at�— 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ED <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) E Hard Hat. <br /> ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) ®Steel toed/shaak shoes or boots. <br /> ❑Noise Sources: ❑flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> E Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> ❑Respirator: ❑APR El <br /> etc ). <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving E 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 by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): (^�'r/ <br /> Plan Approved by: 1 ✓ V r& 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 />