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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION D T EVALUATION OF POTENTIAL HAZARDS <br /> t. Site Name: 3 3 1. Chemiaals Hazards <br /> Address: <br /> ®Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: ( ❑Dusts: <br /> Proposed Date of investigation/inspection:- \ ❑Explosives: <br /> -4Elarnmables: oil filters.solvents <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. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Infotmatio� Tank Capacity: Q 6 PART III <br /> Tank No.: <br /> ftO REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> �e 00� RE <br /> Tank Content 6d. ank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: r aI <br /> operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: ❑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 ❑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 Q C Z D <br /> Physical Concerns:(check all that apply&describe) ®Hard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) ®Safety ed/Glashank shoes. <br /> ❑Noise Sources: ®Steel toed shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): Q Tyvek. <br /> ❑Handling and Transfer of Hazardous Substance:(fire,explosions, Q Respirator: Q APR ❑SCBA <br /> etc..): <br /> Q 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 ElInsects ❑Rodents ❑Poisonous Plants Plan Prepared by: Jeffrey Wong Date: 110 I <br /> Q Other/Unknown(specify): (� I <br /> Plan Approved by: "�l) � 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 />