Laserfiche WebLink
SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> � e <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: ✓� <br /> Contact Person: [�-Carcinogens: <br /> Phone No: L � ❑Corrosives: <br /> Sweeps Number: <br /> Dusts: <br /> Proposed Date of investigation/inspection: --15"0 <br /> El Explosives: <br /> M Flammables: =_�s <br /> 2. Description and brief narrative of inspection activity: ❑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 /> 2.9 p-C. 1,5G,l�, war l,Ye d��rw r PART III <br /> 3. Specific Site Information: II <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. 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: � ti' 7 aC J El Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ('\' <br /> ; El Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: E]YES ElNO El Other,specify. <br /> Documented Groundwater contamination: <br /> [I 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 /> Level of Protection: ElA E]B El 13 D <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) P Hard Hat. <br /> a Hea;ror Cold Stress: ct�)) °F(high ambient temp.) 2-Safety Glasses/goggles. <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ElExcavation:(falls,trips,slipping,cave-ins): Hearing protection. <br /> ElHandling and Transfer of a Hazardous Substance:(fire,explosions, El Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving E'Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> 7 <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants ep y `� <br /> Plan Prepared by: Date: <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: W' I Date: l" <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 />