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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: 1. Chemicals Hazards <br /> Address: <br /> _ El Carcinogens: <br /> Contact Person: l Phone No: ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: MOM12, ❑Explosives: <br /> -Ftammables: A <br /> 2. Description and brief narrative of inspection activity: ❑IInorganic Gases:: <br /> ❑New UST installation. ❑U Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑T ipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑R -excavation. ❑PCB's: <br /> ❑Instal_Iftion of Borings/Monitoring Wells. <br /> 3. gftc Site Information: PART III <br /> Tank No.: Tw ik Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tai ik Age: 1. 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-Ma N& ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contaminatioi r El YES F1 NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previ DUS investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C <br /> Physical Concerns:(check all that apply, describe) ❑Hard Hat. <br /> ❑Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF( igh ambient temp.) <br /> rv'dteel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ❑Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cav -ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardou Substance:(fire,explosions, <br /> El Respirator: [I APR ElSCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&I rauma resulting from moving ❑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 Planprepared by: Date: <br /> ❑Other/Unknown(specify): /,, �Jy, <br /> Plan Approved by:��� Datc: W vV I/ <br /> 8. Narrative(provide all information which ould impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terra) ,etc.) <br /> EH 23081(12/17/2002) <br />