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PART I <br />GENERAL SITE IN <br />1. Site Name: <br />Address: <br />Contact Person: <br />Sweeps Number: <br />Proposed Date of <br />2. <br />3 <br />Description and brief narrative of inspe <br />❑ New UST installation. ❑ U, <br />❑ Tank Closure in Place. ❑ T< <br />❑ Tank/Pipe Removal. ❑ Rt <br />❑ Instalk <br />Iftion of Borings /Monitoring <br />Aite Information: <br />Tank No.: TE <br />Tank Content: Te <br />Other: <br />4. Type <br />5. Release History: <br />Evidence of leaks / soil contamination: <br />Documented Groundwater contaminati <br />Background and description of any pre <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply <br />❑ Hear or Cold Stress: °F <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cat <br />❑ Handling and Transfer of a Hazardot <br />etc..): <br />❑ Confined space entry: (explosions): _ <br />❑ Heavy equipment (physical injury & <br />equipment): <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents <br />❑ Other/Unknown (specify): <br />SITE HEALTH AND SAFETY PLAN <br />Phone No: <br />n activity: <br />Investigation. <br />Pipe Repair. <br />Capacity: <br />Age: _ <br />❑ YES ❑ NO <br />❑ YES ❑ NO <br />investigation or incidence: <br />describe) <br />gh ambient temp.) <br />Substance: (fire, explosions, <br />resulting from moving <br />❑ Poisonous Plants <br />8. Narrative (provide all information which fould impact Health and Safety, <br />e.g., power lines, integrity of dikes, terra) , etc.) <br />EH 23081 (12/17/2002) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />❑ Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />-Ftammables: A <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C 1P <br />❑ Hard Hat. <br />❑ Safety Glasses/goggles. <br />1"70teel 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: Date: <br />Plan Approved by: _ Datc: _61061(2, <br />