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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: I A Fp E <br /> Address: <br /> ®Carcinogens: Used Oil <br /> Contact Person: Phone No: Q Corrosives: <br /> Sweeps Number: I Q Dusts: <br /> Proposed Date of investigation/inspection: ^ 1 ❑Explosives: <br /> ❑Flammables: oil filters.solvents <br /> 2. Description and brief narrative of inspection activity: Q Inorganic Gases: <br /> ❑New UST installation. Q UAR Investigation. <br /> ❑Metals: <br /> Q Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. Q PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Infos tion: PART III <br /> Tank No.: ask Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: 14106ank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Q Combustible Gas/Oxygen Meter. <br /> Q Detector Tubes(Specify). <br /> 4. Type of Operation: <t &U-7 <br /> ❑Photo ionization Detector. <br /> 5. Release History: <br /> Q Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: ❑YES Q 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 OD <br /> Physical Concerns:(check all that apply&describe) <br /> ®Hard Hat. <br /> Safety Glasses/goggles. <br /> Q Hear or Cold Stress: °F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Oxygen Deficiency: Q Flame retardant coveralls. <br /> Q Excavation:(falls,trips,slipping,cave-ins): ®Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, Q Tyvek. <br /> etc..): ©Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> Q Heavy equipment(physical injury&trauma resulting from moving 0 Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> Snakes ❑Insects ❑Rodents ❑Poisonous Plants 22 q Igb <br /> Plan Prepared by: Jeffrey Wong Date:�7 <br /> ❑Other/Unknown(specify): �p <br /> �� 731 <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />