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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE J + I OR IATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: <br /> Ct$ Frt� 1. Chemicals Hazards - <br /> Address: 0 Carcinogens: 0i.Contact Person: QfLf Phone No: <br /> ❑Corrosives: <br /> Sweeps Number: 0 Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: [3 Inorganic Gases: <br /> E]New UST installation. [IUAR Investigation. <br /> ❑Metals: <br /> E]Tank Closure in Place. ElTank/Pipe Repair. <br /> El Oxidizers: <br /> ElTank/Pipe Removal. F1 Re-excavation. <br /> El PCB's: <br /> ElInptallation of Borings/Monitoring Wells. <br /> to ka- or PART III <br /> 3. Specific Site Informatio <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: <br /> operations unless appropriate rationale or restrictions are provided) <br /> / ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: 6 �1 4A ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: _ ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Other,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 /> 6. Potential Health and Safety <br /> Level of Protection: ❑A ❑B ❑C ND <br /> P sical Concerns:(check all that apply&describe) in Hard Hat. <br /> HeaJvr Cold Stress:_°F(high ambient temp.) Safety Glasses/goggles. <br /> ❑Noise Sources: i'®Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): 19 Hearing protection. <br /> El Tyvek. <br /> El Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑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 /> El <br /> (specify): , i Other/UnknownPlan Prepared by: Date: 7—W <br /> Plan Approved by: Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />