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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFO ION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: l i. Cheinieels Hazards <br /> Address: <br /> T <br /> L ®Carcinogens: f <br /> Contact Person: ����Phone No: <br /> ❑Corrosives: <br /> Sweeps Number: <br /> Dusts: - <br /> Proposed Date of investigation/inspection:_ 2nlosives: L� �l i1tiX <br /> )�rlammables: oil filters,solvents <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. �Yetals: <br /> ❑Tank Closure in Place. El 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 /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> �/ ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: �" C L Q ❑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: [D YES C1 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 ®D <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ®Safety Glasses/goggles. <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ®Hearing protection. <br /> E)Handling and Transfer of a Hazardous Substance:(fire,explosions, F1 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 <br /> Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): � r <br /> Plan Approved by: I\ V I Date: � /Z <br /> 8. Narrative(provide all infonnation which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />