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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION�� A T O EVALUATION OF POTENTIAL HAZARDS <br /> L Site Name: ( ,4 � 4 7rJp-T/� � I. Chemicals Hazards <br /> Address: l4' (fJl ( l (Vkavx "" "� EA Carcinogens: <br /> Contact Person: KVIA_k, Phone No: ' /DW 5a Corrosives: <br /> Sweeps Number: KI Dusts: <br /> Proposed Date of investigation/inspection: 1T0�l._T $J Explosives: <br /> aFlammables: <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: 10 <br /> i00 PART III <br /> Tank No.: Dmff� t,Tta�nk Capacity: 10 6�O , �;DO D REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content:_ y AGrzOv-i'Tenk Age: 33 1. Monitoring Equipment(note:Monitoring instrumentsmustused For all <br /> Q operations unless appropriate rationale or reestrictionssare provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> G 5� <br /> [I Detector Tubes(Specify). <br /> 4. Type of Operation: I �' ` <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑1jE5 ®NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: YES [IND <br /> Background and description of any previous investigation or incidence: <br /> �yv per( n�,rtxn 1AXvvu A IAIA tly <br /> T <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ❑D <br /> 6. Potential Health and Safety Hard Hat. <br /> Physical Concerns:(check all that apply&describe) Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) �]Steel toed/sbank shoes or boots. <br /> Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: IRI Hearing protection. <br /> '9 Excavation:(falls,trips,slipping,cave-ins): !❑'Tyvek. <br /> q9 Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator: ❑APR ❑SCBA <br /> etc..): <br /> A/P cartridge: <br /> ❑Confined space entry:(explosions): <br /> To Heavy equipment(physical injury&trauma resulting from moving <br /> Safety vest. <br /> equipment): Two-way communication. <br /> 1A Other,specifyT tlltl(,QPl / <br /> I I PART IV-PLAN APPI�OVAL � <br /> 7. Anticipated Biological Hazards: �^, //,^,,w,/^��A�' <br /> Snakes Insects El Rodents ❑Poisonous Plants Plan Prepared by: M ' /1.�//yy` Date: v o Z— <br /> Other/Unknown(specify): <br /> Plan Approved by: V Date: � !� <br /> 8. Narrative(provide ail information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />