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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION VALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: u am r S Ghemieals Hazards <br /> Address: O a <br /> ®Carcinogens: <br /> Contact Person: <br /> � N F1 Corrosives: <br /> Sweeps Number: `� � � " <br /> (_1 Dusts: <br /> Proposed Date of investigation/insp c'tion:_ ❑Explosives: <br /> lammables: oil filters.solvents <br /> 2. Description and brief narrative of in ection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. C1 Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitor'ig Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: rank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: rank 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: �j� ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contaminatio ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamina ion: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any p 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 ap y&describe) ®Hard Hat. <br /> ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: (high ambient temp.) <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Flame retardant coveralls. <br /> El Oxygen Deficiency: <br /> Hearing protection. <br /> Excavation: falls,tris sli in ve-ins ® <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazard us Substance:(fire,explosions, <br /> Respirator: El APR ElSCBA <br /> etc..): <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 ❑Rodent ❑Poisonous Plants Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): / <br /> Plan Approved by: Date: l <br /> 8. Narrative(provide all information whi could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,t in,etc.) <br /> EH 23081(12/17/2002) <br />