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SITE HEALTH AND SAFETY PLAN <br /> PART PART H <br /> GENERAL SITE INFORM TION�,/[� / ��' EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: � � � rte m0 /CGL-, 1. Chemicals Hazards <br /> Address: :;7 ZO Lc� D-10 ❑Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: Z3^ ❑Explosives: <br /> ,'Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> � f�W l..sPeuFn�� <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: L Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Othec. operations unless appropriate rationale or restrictions are provided) <br /> /�M/ ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: // '`^ �Dc t. ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> ❑ <br /> Evidence of leaks/soil contamination: [I YES ❑NO Other.specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: [I YES [I NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: [IA ❑B El C1D <br /> 6. Potential Health and Safety Hard Hat. <br /> Hat. <br /> Physical Concerns:(check all that apply&describe) <br /> ❑Hear or Cold Stress: OF(high ambient temp.) ❑Safety Glasses/goggles. <br /> ,tg Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ❑Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> ❑Respirator: El APR [ISCBA <br /> etc..): <br /> ❑Confuted space entry:(explosions): AT cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving .ff Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by _Date <br /> ❑Other/Unknown(specify): (t �q <br /> Plan Approved by: w� Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> �. <br /> 4-Q2l i <br /> EH 23081(12/17/2002) <br />