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0 0 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITEe�INFORMATION <br /> � t EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name:�1M1arat fird) k 1-uPA <br /> 1. Chemicals Hazards <br /> Address: _ <br /> Carcinogens: <br /> Contact Person: Phone No: 3 '!2q-n <br /> ❑Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection: 5-9-69 ❑Explosives: r1 <br /> 9 Flammables: Fu¢!l <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> it Me r5�L01 �.t ..y PART III <br /> 3. Specific Site Information: /V\ <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring ins[nunents most be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> (� � ` <br /> E]Combustible Gas/Oxygen Meter. <br /> /��� E]Detector Tubes(Specify), <br /> 4. Type of Operation: LYN1brJ <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> ❑ <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety ,L evel of Protection: ❑A ❑B ❑C ❑D <br /> Physical Concerns:(check all that apply&describe) lrrlt�Jrr Hard Hat. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) w 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): E4 Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, [I Tyvek. <br /> etc..): El Respirator El 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: ,��.p try <br /> [I Snakes El Insects ED Rodents El Poisonous Plants Plan Prepared by: A F'!r. ' C'A Date: <br /> ❑Other/Unknown(specify): <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,em.) <br /> EH 23081(12/17/2002) <br />