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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: rT.W.AA 1. Chemicals Hazards <br /> Address: L <br /> (�t Carcinogens: <br /> Contact Person:UtV6 Phone No: '�4"� 0302 ❑Corrosives: <br /> Sweeps Number: <br /> Proposed Date of investigation/insp ion: <br /> El Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> it QAVW-Z_ -f r's PART III <br /> 3. Specific Site Information: <br /> Tank No.: Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: T k Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> t ❑Combustible Gas/Oxygen Meter. <br /> ❑Detector Tubes(Specify). <br /> 4. Type of Operation: <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamn ati n: ❑YES ❑NO <br /> Background and description of any pre ious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C OD <br /> Physical Concerns:(check all that appl &describe) P�Hard Hat. <br /> 1 f He4or Cold Stress: a °F(high ambient temp.) Safety Glasses/goggles. <br /> ❑Noise Sources: (Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ElExcavation:(falls,trips,slipping,caie-ins): <br /> P Hearing protection. <br /> ElHandling and Transfer of a Hazardoi Substance:(fire,explosions, El Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions):_ A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving DFSafety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify / <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: a� <br /> El Snakes El Insects ❑Rodents El Poisonous Plants <br /> Plan Prepared by: � Date: 7—� VO <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all information whichlcould impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />