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0 4 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART R <br /> GENERAL SITE INFORMwwA"T��I�"�ONS�"� (� EVALUATION OF POTENTIAL HAZARDS <br /> L SiteName: I_W' Irw�+t nv�Q, cwn� <br /> 1. Chemicals Hazards <br /> Address: �\ _���' SAW\ IN <br /> Concoct Person: `lir'r`+"r� t-44Wyl Phone No:-J�6 <br /> ❑Corrosives: <br /> Sweeps Number: ®Dusts: <br /> Proposed Date of investigation/inspection: <br /> ❑Explosives: <br /> (�Flammables: � <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation <br /> ���oof��Borings/Monitoring Wells. <br /> 3. SMpeciO Sice �lrInformation: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments most be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> ���,(�� 1,,�,r,,,�1�`' ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: iv`k vxx'"rIw'OvP' Y K�f S�1E� ❑ 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: []YES El 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 Level of Protection: ❑A ❑B ❑C C9D <br /> 8 Hard Hat. <br /> Physical Concerns:(check all that apply&describe) [Safety Glasses/goggles. <br /> Heater Cold Stress: Ol0 OF(high ambient temp.) <br /> ❑Noise Sources: Steel toed/shank shoes or boots. <br /> ❑ <br /> Oxygen Deficiency: Flame retardant coveralls. <br /> ❑ <br /> ❑Excavation:(falls,trips,slipping,cave-ias): [+xHearmg protection. <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): AT 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: p„ �, �_- ,( <br /> ❑Snakes El Insects ❑Rodents [I Poisonous Plants Plan Prepared by: -kW <br /> ' — C Z Date: <br /> ❑Other/Unknown(specify): <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 />