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SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: �AnY.�IZ, iGra r'�fMwni �KD�L� 1. Chemicals Hazards <br /> Address: 1t 4 • L t ll <br /> carcinogens; Q +Qete <br /> Contact Person: TOu,D F3C+IS4arrof Phone No: ,l <br /> Corrosives: S� 160 Rw wi1a'Ik S <br /> Sweeps Number: ❑Dusts: I <br /> Proposed Date of investigation/inspection: 11-2R-Ib <br /> ❑Explosives: <br /> M lanunables: ar <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: fr <br /> ❑New UST installation. ❑UAR Investigation. Metals:� e6uW iya6- CNI�iNaS <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> rHa <br /> 3. Specific fic Site InInformation: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instrtmunts must be used fm all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> P" [� � L'- c+�� ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: l WC(�YQVCNV ' Q^VTce- ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO ❑gym•specify. <br /> Documented Groundwater contamination: <br /> ❑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 /> Level of Protection: ❑A ❑B El OD <br /> 6. Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) gj'Hard Hat <br /> 'Safety Glasses/goggles. <br /> ❑Heater Cold Stress: °F(high ambient temp.) Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cavo-ins): 'p Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&tmurna resulting from moving NMafety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes 0Insects ❑Rodents ❑Poisonous Plants <br /> Plan Prepared by: Data: <br /> ❑Other/Unknown(specify): <br /> � <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: � Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />