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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATIO EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: ( I. Chemicals Hazards <br /> Address: 0 _�1 Carcinogens: <br /> Contact Person: u4b. Phone No: (� Corrosives: <br /> Sweeps Number: <br /> El Dusts: <br /> Proposed Date of investigation/inspect'on: ❑Explosives: <br /> —Er—Flammables: <br /> 2. Description and brief narrative of ins ction activity: Ji Inorganic Gases: <br /> ❑New UST installation. ❑ UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. r.A ❑PCB's: <br /> ❑Installation of Borings//Mofnitorin Wells. UQ kA)- <br /> �Ua6360L <br /> 3 PART III <br /> 3. Specific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. 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 <br /> ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contaminat on: El YES F1 NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any pn vious 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 app y&describe) ❑Hard Hat. <br /> ❑Hearor Cold Stress: (high ambient temp.) F1 Safety Glasses/goggles. <br /> ❑Noise Sources: ❑Steel toed/shank shoes or boots. <br /> El Oxygen Deficiency: F]Flame retardant coveralls. <br /> ElExcavation:(falls,trips,slipping,cave-ins): ❑Hearing protection. <br /> ❑Handling and Transfer of a Hazard DUS Substance:(fire,explosions, F-1 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 ❑Roden s ❑Poisonous Plants3 <br /> Plan Prepared by: �'-Datc. <br /> F1 Other/Unknown(specify): <br /> Plan Approved by: QU Date: <br /> 8. Narrative(provide all information whi h could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,tei rain.etc.) <br /> 1:11 23081 (12/17/2002) <br />