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PART I <br />GENERAL SITE INFORMATIION <br />1. Site Name: MCG/ <br />Address: <br />Contact Person: <br />Sweeps Number: <br />Proposed Date of investigation/ins <br />2. Description and brief narrative of im <br />❑ New UST installation. ❑ <br />❑ Tank Closure in Place. ❑ <br />❑ Tank/Pipe Removal. ❑ <br />❑ Installation of Borings / Monitori <br />3. Specific Site Information: <br />Tank No.: <br />Tank Content: <br />Other: <br />4. Type of Operation: <br />5. Release History: <br />Evidence of leaks / soil contaminat. <br />Documented Groundwater contami <br />Background and description of any <br />6. Potential Health and Safety <br />Physical Concerns: (check all that aP1 <br />❑ Hear or Cold Stress: <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, <br />❑ Handling and Transfer of a Hazan <br />etc..): <br />❑ Confined space entry: (explosions <br />❑ Heavy equipment (physical injury <br />equipment): <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ 1 <br />❑ Other/Unknown (specify): _ <br />SITE HEALTH AND SAFETY PLAN <br />Phone No: U <br />>n:_ <br />:tion activity: <br />�R Investigation. <br />nk/Pipe Repair. <br />excavation. <br />Wells. <br />nk Capacity: <br />tilt Age: <br />4 <br />C4C _� <br />❑ YES ❑ NO <br />n: ❑ YES ❑ NO <br />ious investigation or incidence: <br />& describe) <br />(high ambient temp.) <br />Substance: (fire, explosions, <br />trauma resulting from moving <br />❑ Poisonous Plants <br />8. Narrative (provide all information whish could impact Health and Safety, <br />e.g., power lines, integrity of dikes, t in, etc.) <br />EH 23081 (12/17/2002) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1 Chemieels Hazards <br />f ® Carcinogens: 2 j l -A; <br />7�► I ❑ Corrosives: i A D Ian _ A C.A C <br />❑ Dusts: <br />❑ Explosives: t TPrV ftb,,j�P21 <br />❑ Flammables: oil filters, solvents filters, solventsa���� <br />❑ Inorganic Gases: I <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ® D <br />® Hard Hat. <br />® Safety Glasses/goggles. <br />® Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />® Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />® Safety vest. <br />❑ Two-way communication <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: Jeffrey Wong Date: 6 lrP-io [J <br />Plan Approved by: Date: <br />