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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION, EVALUATION OF POTENTIAL HAZARDS <br /> I. Address:e: OL60 N .1. Chemicals Hazards((�� y� <br /> [PCaroinogens: YWY^ A+ 1 eA-S <br /> Contact Person: Phone No: <br /> ❑Corrosives: <br /> Sweeps Number: 1P Dusts. <br /> Proposed Date of investigation/inspection: I O—I$'QPi ❑Explosives: <br /> Flammables: a -�iiMQ g�{j1VPn <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. <br /> F_]Tank Closure in Place. ❑Metals: <br /> ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> n_ <br /> 3. Specific Site Information's PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> S ❑Combustible Gas/Oxygen Meta. <br /> 4. Type of Operation:�A9a �D�y ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyza. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑mer'specify. <br /> Documented Groundwater contamination: ❑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 /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C D <br /> Physical Concerns:(check all that apply&describe) Ip Hard Hat. r <br /> ❑Hear or Cold Stress`-- —OF(high ambient temp.) Ib Safety Glasses/goggles. <br /> ff)Noise Sources: wl 2 Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: —�V F ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): 2 Hing protection. <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): r,A A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving Safety vest. <br /> equipment): Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: y� <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: Dale: <br /> ❑Other/Unknown(specify): <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: U4� Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />