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SITE HEALTH AND SAFETY PLAN <br /> PART I S �'� PART II <br /> GENERAL SITE INFOAMATION �.• EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name:- I 1y��L� �� } FhemieaIs Hazards <br /> Address: O Carcinogens: <br /> Contact Person: M!t/k —(/I�gPhone No: �3 rrrosives: Ll i 2 'f � <br /> l <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:_ C1 Explosives: <br /> ❑Flammables: oil filters solvents <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 /> PART III <br /> 3. Specific Site Information: <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 /> operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> S r7✓ /i W n,_ ❑Detector Tubes(Specify) <br /> pe of Opera . <br /> 4. Tytion: 'l t'iY <br /> Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ®D <br /> 6. Potential Health and Safety ®Hard Hat. <br /> Physical Concerns:(check all that apply&describe) ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: 'F(high ambient temp.) ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, E)APR E)SCBA <br /> ❑Respirator. <br /> etc..): A/P <br /> Confined space entry:(explosions): Safety <br /> cartridge: <br /> ❑ Pa rY�( P )� <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: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): ln <br /> Plan Approved by: P U I` Date: <br /> S. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power Ii es,intcgrityrof dikes in,ety. <br /> PH 2i0R1 M/17/20021 <br />