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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: ria_ L-, -7 (, 1. Chemicals Hazards <br /> Address: 12.4-4 6 in-1.1— L_ ❑Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: `/It 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. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. <br /> 3. P ifi Sit1-4 e]nfnrmatta�n 4-r PARI'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 /> ❑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: E]YES ❑NO ❑Other,specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES El NO <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 -KD <br /> Physical Concems:(check all that apply&describe) _54:jfard Hat. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) Safety Glasses/goggles. <br /> ''Steel toed/shank shoes or boots. <br /> F1 Noise Sources: <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> El Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): (3 Tyvek. <br /> �H�lIandling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): E]Respirator: ElAPR ❑ SCBA <br /> ❑Confined space entry:(explosions): AIP cartridge. <br /> ❑Heavy equipment(physical injury&trauma resulting from moving Safety vest. <br /> equipment): Two-way communication. <br /> ❑Other,specify <br /> PART N-PLAN APPROV <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared Datek/ <br /> ❑Other/Unknown(specify): (� <br /> Plan Approved 1 C 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 />