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SITE HEALTH AND SAFETY PLAN <br />PART <br />GENERAL SITE INFORMAT ON , I %p�r�� �� e <br />1. Site Name: M Y2 am //6LA <br />Address: 1 s) �tQST <br />Contact Person: Nn jWY-✓" Phone No: <br />Sweeps Number. <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation. ❑ UAR Investigation. <br />❑ Tank Closure in Place. ,❑p Tank/Pipe Repair. <br />tar <br />❑ Tank/Pipe Removal. Ae-.m?Atton,H-bJ <br />❑ Installation of Borings / Monitoring Wells. <br />3. Specific Site Information: <br />Tank No.: Tank Capacity: <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />❑ Carcinogens: <br />Cl Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />WFlammables: <br />❑ Inorganic Gases: <br />IA Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank Content: Tank Age: <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />Other: <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />4. Type of Operation: _ 0-4w f �-ry„,Illm"Photo <br />Detector Tubes (Specify). <br />—F <br />I <br />Detector. <br />❑ Organic Vapor Analyzer. <br />5. Release History: <br />C] Other, specify. <br />Evidence of leaks /soil contamination: ❑YES [INO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />6. <br />Background and description of any previous investigation or incidence: <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: OF (high ambient temp.) <br />❑ 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 />eauinment). <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes (N 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 />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ❑ D <br />❑ Hard Hat. <br />❑ Safety Glasses/goggles. <br />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 />0 Two-way communication. <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: N IM j)-tA Date: a i7 d 0 <br />Plan Approved by: Date: <br />