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SITE HEALTH AND SAFETY PLAN <br /> PART I PART H <br /> GENERAL SITE INFO ATI N ^ EVALUATION OF POTENTI)L HAZARDS /I <br /> 1. Site Name: r^ Is Hazards <br /> Address: ,t (n Carcinogens:X y <br /> Contact Person: Oldby., Phone No: <br /> Sweeps <br /> Sweeps Number: jR" ❑Dusts: <br /> Proposed Date of investigation/inspectiorn- ❑Explosives: <br /> 2. Description and brief narrative of in El Flammables: oil filters,solvents <br /> p inspection activity: <br /> C:)Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. - I <br /> [D Metals:� IAMf k .rr—Ele-�$1� <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. 0 % Vz C— <br /> D e!y <br /> 3. Specific Site Information: 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 /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: �r� ❑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 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) ®Hard Hat. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) ®Safety Glasses/goggles. <br /> ❑Noise Sources: ®Steel toed/shank shoes or boots. <br /> ❑Oxygm Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ®Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, [I Tyvek. <br /> ac..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): 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: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unlmown(specify): Plan Prepared by: Jeffrey Wong Date: <br /> Plan Approved by: V Date: <br /> 8. Narrative(provide all information which could impact Healon and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />