Laserfiche WebLink
0 6 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INF RMAT N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: i 1. Chemicals Hazards <br /> Address: vy\ [�J Carcinogens: l - <br /> Contact Person: F Phone No: ❑Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection: �8® <br /> ❑Explosives: <br /> Flammables• <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Meds: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> tp <br /> '' PART III <br /> 3. Speci is Site ti <br /> Informao : <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 /> operations unless appropriate rationale of restrictions are provided) <br /> Other: <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: F-1YES ❑NO [I Other,specify. <br /> Documented Groundwater contamination: <br /> ❑YES ❑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) J�PHard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) Safety Glasses/goggles. <br /> Steel toed/shank shoes or boots. <br /> El Noise Sources: <br /> ElFlame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> E]Excavation:(falls,trips,slipping,cave-ins): ®Hearing protection. <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> El ❑APR ❑SCBA <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 /> El Snakes ❑hisects ❑Rodents ❑Poisonous Plants Plan Prepared by: git!s Date: (,d6 <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,ten-din,etc.) <br /> EH 23081(12/17/2002) <br />