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SITE HEALTH ANIS SAFETY PLAN <br />PART I <br />GENERAL SITE INFORMATION <br />1. Site Namc:prr <br />Address: 7, –7 A �,, . <br />Contact Person:Phone No: R37-- <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation. <br />❑ UAR Investigation. <br />❑ Tank Closure in Place. <br />❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. <br />❑ Re -excavation. <br />❑ Installation of Borings / <br />Monitoring Wells. <br />1-1 q S 1) <br />-5 ]r.`. <br />1 <br />3. Specific Site formation: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. Type of Operation: 001— h iC'C_4" ,5 <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: *F (high ambient temp.) / <br />Ralloise Sources: 1— <br />❑ Oxygen Deficiency: <br />ARExcavation: (falls, trips, slipping, cave-ins): '51 L–,e S <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify <br />Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />& Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.) <br />EH 23081 (12/1712002) <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />❑ Carcinogens: <br />❑ Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />,Q'Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />El Orgastic Vapor Analyzer. <br />❑ Other, specify. <br />tf monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B <br />❑ Hard Hat. <br />Safety Glasses/goggles. <br />Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR <br />A/P cartridge: <br />,%�,Safcty vest. <br />Two-way communication. <br />❑ SCBA <br />PART IV - PLAN APPPRR ,OVAL <br />Plan Prepared b i` �7 _ Date: �/=~ <br />Plan Approved by: Date: <br />