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6 <br />SITE HEALTH AND SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: <br />.2�r-1J� AyNa" Ww X;Y Ulr� <br />Address: -``tfWM Q <br />Contact Person: Phone No: <br />Sweeps Number: <br />Proposed Date of investigation/inspection: 10-11 -N <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation. <br />❑ UAR Investigation. <br />❑ Tank Closure in Place. <br />❑ Tank/pipe Repair. <br />❑ Tank/Pipe Removal. <br />❑ Re -excavation. <br />❑ Installation oof� Borings / <br />Monitoring Wells. <br />to ( r64'ty / <br />L� <br />AI4" WypQ(aj2N <br />3. Specific Site Information: <br />1 <br />Tank No.: <br />Tank Capacity: <br />Tanks <br />Other: <br />Tank Age: <br />4. Type of Operation: Tft�Ak,& 1 <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals nerds (An' f�f _ I <br />® Carcinogens: 01 � i f�t�J( a,�l�c . NS$'K P4� <br />❑ Corrosives: <br />Dusts: <br />❑ Explosives: <br />M Flammables: &. 6& u x'i <br />❑ Inorganic Gases: ` �� 11` f' <br />Metals: s" d 4*6'rSoleO I.AIM (Pa. <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />Documented Groundwater contamination: El YES El NO If monitoring instruments are not used, rationale or activity / area restrictions: <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />WA <br />Physical Concerns: (cbeck all that apply & describe) <br />❑ Hear or Cold Stress: OF (high ambien'tttemp.) <br />0 Noise Sources: dALtA�iu. \ Lh, 4fAl— <br />� <br />❑ Oxygen Deficiency <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury &trauma resulting from moving <br />cormament): <br />❑ Other, specify <br />Anticipated Biological Hazards: <br />Asnakes M Insects 10 Rodents <br />❑ Other/Unknown (specify): <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C PUD <br />lard Hat. <br />Safety Glasses/goggles. <br />u Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />19 Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />Safety vest. <br />❑ Two-way communication. <br />PART IV -PLAN APPROVAL <br />❑ Poisonous Plants Plan Prepared by: �— Dale:' <br />Plan Approved by: <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 />Date: <br />