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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO TION Q G ` EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: is Hazards <br /> Address: 1h ®Carcinogens: <br /> Contact Person: hone No: q 3 e R� �y,�G. <br /> —1�— ❑Corrosives- u t <br /> Sweeps Number: ❑Dusts: ria9 a Zor <br /> Proposed Date of investigation/inspection:_ ❑Explosives: <br /> �:Flammables: oil filters solvents a �Vl-q <br /> 1 <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: C&rl h& .o 1 ieJ_ s <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 /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: C( d- �jp�,d s ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> Evidence of leaks/soil contamination: El YES [3 NO E)Other,specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES F1 NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ®D <br /> 6. Potential Health and Safety <br /> ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) <br /> ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> ®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, ❑APR ❑SCBA <br /> etc..): EJ Respirator: <br /> El Confined space entry:(explosions): cartridge: <br /> El Heavy equipment(physical injury&trauma resulting from moving ®SSafety 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: Jeffrey Wong Date: 0 <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: V� Date: <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 />