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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE"FOAT, N EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: I. Chemicals Hazards <br /> Address: y'�✓ �} <br /> Carcinogens: <br /> Contact Person:1 Phone No: ` 74 <br /> ❑Corrosives: <br /> Sweeps Number: <br /> El Dusts: <br /> Proposed Date of investigationhnspection: ❑Explosives: <br /> P Flammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> tM 0�� RL' '(',,A q PART III <br /> 3. Specific Site Information: <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 /> !� (�, <br /> El Combustible Gas/Oxygen Meter. <br /> El Detector Tubes(Specify). <br /> 4. Type of Operation: { n� L 1 < t 1 <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: <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) t�Hard Hat. <br /> [�Hea;'or Cold Stress: W <br /> °F(high ambient temp.) Safety Glasses/goggles. <br /> �V r <br /> Noise Sources: (r�Steel toed/shank shoes or boots. <br /> Q <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> Hearing protection. <br /> ❑Excavation:(falls,trips,s ipping,cave-ins): <br /> Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): pp8p,,A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving YJ Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Bi logical Hazards: <br /> ❑Snakes Insects ❑Rodents ❑Poiso ous Plants <br /> Plan Prepared by:��Date: <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,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />