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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: <br /> ,.! I. Chemicals Hazards <br /> Address:_ !�rj SJ122tddkZ= C i7✓e— <br /> ❑Carcinogens: <br /> Contact Person: ln—rr Q Phone No: 4221— `>`l`i� <br /> ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: r /`f 11 ❑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 /> M. H-;?; .- 0_' ( J�.s/z fid- � h., <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 /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: C]YES ❑NO C1 Other,specify. <br /> Documented Groundwater contamination: ❑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 ER D <br /> Physical Concerns:(check all that apply&describe) Hard Hat. <br /> Hear oo Stress: °F(high ambient temp.) Ja Safety Glasses/goggles. <br /> ❑Noise Sources: 'Q Steel toed/shank shoes or boots. <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ❑Excavation:(falls,trips,slipping,cave-ins): Hearing protection. <br /> ❑ <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving 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 Date: <br /> ❑Other/Unknown(specify): G <br /> Plan Approved y: Date: b <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 />