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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITEF AT N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1%n 'l 'iP11WY 1. Chemicals Hazards,,,, <br /> Address: eFM - ( [NCaroinogens: YIX,tI'U�1Aw1 ("�1 <br /> Contact Person: VMW *r/FS Phone No:3(.4 ---Ull ❑Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection: A P 00 ❑Explosives: <br /> 121 Flammables: _ <br /> 2. Description and brief narrative of inspection activity: t <br /> [I Inorganic Gases: <br /> ❑New UST installation. ❑LAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Be rings/Monitoring Wells. <br /> { �01 wNy PART III <br /> 3. Specific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used fm all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: <br /> �0 ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/and contamination: ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: <br /> ❑YES ❑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 )qD <br /> Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> [q Hekor Cold Stress: -F(high ambient temp.) <br /> ❑Noise Sources: Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-firs): ®Hearing protection. <br /> E]Handling <br /> Tyvek.Handling and Transfer of a Hazardous Substance:(fire,explosions, ElResphator: [IAPR LlSCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): q A/P cartridge: <br /> El , <br /> Heavy equipment(physical injury&trauma resulting from moving 1I Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: •` _I <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants plan Prepared by: Date; <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: „4y.(..�29 IA"te: <br /> 8. Narrative(provide all information which could impact Health and Safety, CCC <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />