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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION <br /> p EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: CWA " _' `fit 1. Chemicals Hazards <br /> Address: VT NCarcinogens: <br /> Contact Person: L&- Phone No:333-<a 18 <br /> ❑Corrosives: <br /> Sweeps Number: [I Dusts: IK <br /> Proposed Date of investigation/inspection: —�`�-01 <br /> ❑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 /> ❑USTretrofit/repair 09 R" ("k-el 1,,;,s}to <br /> 3. Specific Site Information: f 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: A4 ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑ NO ❑Other,specify. <br /> Documented Groundwater contamination: YES El NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> ❑ <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 D <br /> Physical Concerns:(check all that apply&describe) [ Hard Hat. <br /> [� <br /> ElHea#'or Cold Stress: °F(high ambient temp.) Safety Glasses/goggles. <br /> [� <br /> Noise Sources: Steel toed/shank shoes or boots. <br /> ❑ <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> L3Excavation:(falls,trips,slipping,cave-ins): ]Hearing protection. <br /> ElHandling 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 PlantsA — 4 <br /> Plan Prepared by: � <br /> El Date' <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: 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 />