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SITE HEALTH AND SAFETY PLAN <br /> PARTI PARTII <br /> GENERAL SITE INFORMATIONo �,(/ EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: .LI C' 1, S �h � `M f.�tiH/\ <br /> �—p F 1. Fltemieels Hazards <br /> Address: <br /> E Carcinogens: <br /> Contact Person:� e ( tNM0 Phone No: q 4�—I 0 ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:_ <br /> ❑Explosives: <br /> tion and brief narrative of in �ammables: oil filters.solvents <br /> 2. Description inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. E�r/ <br /> _JgMetals: <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. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content Tank Age: L 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: <br /> ❑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 /> OC <br /> Documented Groundwater contamination: NO❑YES <br /> ❑ If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Backgoupd and description of any pm"ou investigation or incidence: <br /> N 'A <br /> ✓5�� SQL/ p GA-/ <br /> LLVV <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ED <br /> Physical Concerns:(check all that apply&describe) E Hard Hat. <br /> F.]Hear or Cold Stress: OF(high ambient temp.) E Safety Glasses/goggles. <br /> ❑Noise Sources: E Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): E Hearing protection. <br /> C3Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: [D APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving E 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 plan Prepared by: Jeff Wong Date: 1 <br /> ❑Other/Unknown(specify): a <br /> Plan Approved by: Date: Se« 1 y <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 />