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SITE HEALTH AND SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: &ON, G"S <br />Address: 990 URi^' �• <br />Contact Person: �_ Phone No: 09SP <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <br />2. <br />3. <br />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 of Borings / Monitoring Wells. <br />gi & it <br />Specific Sitt Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: <br />Tank Age: <br />Other: <br />4. Type of Operation <br />s <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: OF (high ambient temp.) <br />P Noise Sources: <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 />eauioment): <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <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 />PART II 1 <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />® Carcinogens: <br />❑ Corrosives: <br />® Dusts: <br />❑ Explosives: <br />4 Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. 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 />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ❑ D <br />[!J Hard Hat. <br />[3 Safety Glasses/goggles. <br />j�? Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />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 />-(rPlan Prepared by: % Date: �� <br />Plan Approved by: �N1" Date: <br />