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SITE HEALTH AND SAFETY PLAN <br /> PART PART II <br /> GENERAL SITE//INFORMATION� � p �� -r' EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name. &eA, sea f7 Yq MF'.fl.il Y`1l _�.J1 1. Chemicals Hazards .� gg <br /> Address: f D Y� S (f�iYD�CPP 1 4 LL ❑Carcinogens: -0. \MnI4 Wi <br /> Contact Person(-'Ai II11A-rid6,mv-1 _Phone Noz,1� ( Cn ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Daze of investigation/inspection: ❑Explosives: <br /> ❑Flamnables: IA/a Ap. m <br /> 2. Description and brief native of inspection activity: ❑Inorganic Gases: be j i o In04 Pitt F YI+ <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 /> ®Hazardous Waste Inspection PART III <br /> 3. Specific Site Information: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:Aod''/r-ilk, i ,N".6,� E)Detector Tubes(Specify). <br /> "�T ❑Photo ionization Detector. <br /> 5. Release History: ElOrganic Vapor Analyzer. <br /> Evidence of Teaks/soil on C]YES C]NO C]Other,specify. <br /> Documented Groundwater contamination: [I YES F1 NO If monitoring mstnunents 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 RD <br /> Physical Concerns:(check all that apply&describe) ❑Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ❑Safety Glasses/goggles. <br /> ❑Noise Sources: (Steel toed/shank shoes or boots. <br /> ❑ <br /> El Oxygen Deficiency: Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cavemins): ❑Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> eta.): ❑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 /> Plan Prepares by: l'--rf—l HL Date: <br /> ❑Other/Unknown(specify): '•aJ( <br /> Plan Approved by: "`^' Date: �•1��t Q <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,twain,etc.) <br /> EH 23081(12/17/2002) <br />