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SITE HEALTH AND SAFETY PLAN <br /> PART PART II <br /> GENERAL SITE INFORM'ATI'ON I /n� 1 EVALUATION OF POTENTIAL HAZARDS <br /> I. Site Name: UNI tte,/ ^�'_ lF:,1,1 . T fi ,p 1. Chemicals Hazards <br /> Address: 7"-JAI-0 I v uw�-'l RLJo�t`( �(VLhTn ElCarcinogens: <br /> Contact Person: SCwA-lam Phone No: 'IR4—SSZ.Sb C]Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: 14s; l9 catxplosives: <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 Repaw ❑Oxidizers: <br /> ❑Tank/Pipe Removal. OF 5 Cl PCB's: <br /> ❑Installation of Borings/Monitoring e <br /> '3. 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 /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ��`/\ � 1 I - }- <br /> C]Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: A(fNC_Q liN1r ❑erector Tubes(Specify). <br /> F ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO ❑mer'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 Level of Protection: ❑A ❑B ❑C ❑D <br /> Physical Concerns:(check all that apply&describe) [hard Itat <br /> ,.,/ [Safety Glasses/goggles. <br /> Ry H"r or Cold Stress: °F(high ambient temp.) <br /> ❑ <br /> Noise Sources: [Steel toed/shank shoes or boots. <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: B'h <br /> �nearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> t❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator: ❑APR ❑SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): AT cartridge: <br /> [O'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 BiootoJp�'Cal Hazards: <br /> Ly Jnakes 'Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: ''r` ` '" ' 'r�M Date: <br /> ❑Other/Unlmown(specify): ., ,p,.,.�I.1Af \ X <br /> Plan Approved by: �"_ wr"" Date '?v <br /> 8. Narrative(provide all information which could impact Health and Safer),, <br /> e.g.,power lines,integrity of dikes,terain,etc.) <br /> EH 23081(12/17/2002) <br />