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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: F 1. Chemicals Hazards <br /> Address:7�S`� /Air. rte ,._ <br /> ❑Carcinogens: <br /> Contact Person: r_1'k h1 - Phone No: Q 3 t p 7 cJ c'� ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection:_I D —2'-F—/l ❑Explosives: <br /> ❑Hammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑ PCB's: <br /> _❑1Installation of Borings/Monitoring Wells. <br /> 3. <br /> Specific, ite Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: r' ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑mar'specify. <br /> Documented Groundwater contamination: C]YES F1 NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C &D <br /> Physical Concerns:(check all that apply&describe) 25--€iard Hat. <br /> F-1Hear or Cold Stress: °F(high ambient temp.) a Safety Glasses/goggles. <br /> ❑Noise Sources: ,e+Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> F-1Excavation:(falls,trips,slipping,cave-ins): 52�Hearing protection. <br /> Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc ): El Respirator: ❑APR F]SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> tSkHeavy equipment(physical injury&trauma resulting from moving Z%afety vest. <br /> equipment): Two-way communication. <br /> ❑Other,specify <br /> PART IV;-PLAN APPR VAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects C1Rodents ❑Poisonous Plantsplan PrepareDate: <br /> ElOther/Unlmown(specify): <br /> Plan Approved y: Date: d �� <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 />