Laserfiche WebLink
i 1 <br /> TH DIVISION <br /> COUNT-Y E�]VIRON IE FTY�PLAN <br /> Stu`3 30AQUIN SITE HEALTH As' T3 SAF <br /> PART 11S <br /> EVALUATION OF POT <br /> FART ITION <br /> MA 1 C carc als Hazards <br /> GENERAL SITE INFOR <br /> t � � [r� arcinogens: <br /> 1r' °e� [] Corrosives: <br /> 1. Site Name= `��r y <br /> Address: 7 �' 11� Phone No. " [} Dusts: <br /> Contact Person: l [ ] xplosives: <br /> SweeQ <br /> s Number: lammables: <br /> proposed Date of investigation/inspection: v [ ] Inorganic Gases: <br /> action activity: [] Metals: <br /> �. Description and brief narrative af[ij UAR Investigation [ ] Oxidizers: <br /> [ } New UST Installation [ ] Tank/Pipe Repair []PCB's: <br /> [ ] Tank Closure in Place [ } Re-eXcavation <br /> [,, tank/Pipe Removal Wells PART III <br /> [ ] Installation of Borings/M°nitoring RFQ� PI~RSONAL.P-OTECINE <br /> FQUIPMENI' <br /> 3. Specific Site Information: 1 Ci�s � <br /> Tank Capacity: �r 1 ui trent: (nate: Monitoring <br /> Tank No. e7 J Tank Age: - � 1, Monitoring Eq p <br /> Tank Contents: , instruments must be used for all operations <br /> Other: N) unless appropriate rationale or restrictions are <br /> q Type of Operation: <br /> cc) , provided) <br /> [,Combustible Gas/Oxygen Meter <br /> 5. Release History: �yFS [ I NO [] Detector Tubes (Specify) <br /> Evidence of leaks/soil contamination: [`°1 YES [v,NO [ } Photoionization Detector <br /> Documented Groundwater contaminaC�onnQu investigation [] Organic Vapor Analyzer <br /> Background and description of any p [ ] Other, specify: <br /> or incidence: 3rr1��+ C � �t� If monitoring instruments are not used, <br /> y rationale or activity/area restrictions: <br /> b. Potential.Health and Safety <br /> Physical Concerns: (check all that apply & describe) <br /> [,Heat or Cold Stress: °F (high ambient temp.) <br /> 2. Personal Protective Equipment <br /> [v�Noise Source: Level of Protection: [ ]A [ ]B [ ]C V16 <br /> [ J Oxygen Deficiency: [fHard hat <br /> [excavation: (falls, trips ,slipping, cave-ins)_�� ,, Safetglasses/goggles <br /> [ Handling and Transfer of a Hazardous Substance: [ } �' <br /> [Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) <br /> [ ] Flame retardant coveralls <br /> Confined Space entry: (explosions) [ ] <br /> [„]'Heavy equipment (physical injury & trauma resulting [,• Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> ] Respirator, circle: APR or SOBA <br /> [ ] Other, specify A/P cartridge: <br /> [ ] Safety vest <br /> 7. Anticipated Biological Haza s: ��f-� �� <br /> G [ ] Two-way communication <br /> [ ] <br /> Snakes; [ ] Insects (4 Rodents [ ] Poisonous Plants PART IV <br /> [ ] Other/Unknown (specify): PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date: ' Z+ qi <br /> Flan Approved by: lute: `v k(� I <br /> 12 <br />