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SITES HEAL AND SAFETY PLAN <br />P Ctr0 TO PART II <br />ENERAL SITE INF ATI N s EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: is Hazards A' <br />Address: Ke <br />® Carcinogens: <br />Contact Person: Phone No: r_1 Corrosives: <br />Sweeps Number: Dusts: <br />Proposed Date of investigation/inspection: _ <br />❑ Explosives: <br />l I ❑ Flammables: oil filters. solvents <br />2. Description and brief narrative of inspection activity: �(� T l <br />111 ❑Inorganic Gases: <br />❑ New UST installation. ❑ UAR Investigation. ❑ Metals: <br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair. ❑ Oxidizers: <br />❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ PCB's: <br />❑ Installation of Borings / Monitoring Wells, <br />3 PART TTT <br />4. <br />5. <br />ba <br />F] <br />Specific Site Information <br />Tank No.: Tank Capacity: <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank Content: Tank Age: <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />Other. <br />❑ Combustible Gas/Oxygen Meter. <br />Q rlj,. <br />❑ Detector Tubes (Specify). <br />Type of Operation: <br />ro ,{ r� <br />t <br />El Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />Release History: Q. <br />Sk `tl d'4 . ®vw <br />ttt% i3. /'iA ❑ Other, specify. <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: C1 YES ❑ NO <br />If monitoring instruments are not used, rationale or activity /area restrictions: <br />Background and description of any previous investigation or incidence: <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify <br />Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents <br />❑ Other/Unknown (specify): <br />❑ Poisonous Plants <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 />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:��AW/201/ <br />Plan Approved by: X Date: < <br />