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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: !�& p Tf -" f (t,3r, 1. Chemicals Hazards <br /> Address: I t c,- (Carcinogens: <br /> Contact Person: Ayh" Phone No: <br /> ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigationlinspection:i dQ EiKxplosives: <br /> E'C+lammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑T f�ipe Repair. El Oxidizers: <br /> ❑Tank/Pipe Removal. El ' ❑PCB's; <br /> ❑Installation of Borings/Monitoring Wells. <br /> 1. Specific Site Information: PART III <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 /> /r <br /> � <br /> F1 Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: 6AU �Twhr^ ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> S. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks 1 soil contamination: <br /> ❑YES ❑NO ❑mer'specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: E]YES C3 NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ❑ D <br /> 6, Potential Health and Safety <br /> Physical Concerns:(check all that apply&describe) El Hard Hat. <br /> ❑Safety Glasses/goggles. <br /> Hear or Cold Stress: °F(high ambient temp.) <br /> �i4el toed shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ❑Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑APR ❑SCBA <br /> etc..): ❑Respirator: <br /> ❑Confined space entry:(explosions): Safety <br /> cartridge:vest. <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): Rwo-way communication. <br /> (ji`Other,specify '72AT-1WVG <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: J�/ <br /> ❑Snakes nsects F1Rodents F-1PoisonousPlants Plan Prepared by: / � Date: D� <br /> ❑OtherlUnknown(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 (1211712002) <br />