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SITE HEALTH AND SAFETY PLAN <br />PART I <br />PART II <br />GENERAL SITE INFORMPPON <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: <br />� <br />I . Che ocals Hazards <br />Address: <br />1 <br />Qom, c�aromogens: <br />Contact Person: b Phone <br />❑Corrosives: <br />Sweeps Number: <br />❑ Dusts: <br />Proposed Date of investigation/inspection: <br />❑ plosives: <br />Pbles: <br />2. Description and brief narrative of inspection activity: <br />❑ Inorganic Gases: <br />❑ New UST installation. ❑ UAR Investigation. <br />❑ Metals: <br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair. <br />❑ Oxidizers: <br />❑ Tank/Pipe Removal. ❑ Re -excavation. <br />❑ PCB's: <br />El Jnstallation of onngs / Monitoring Wells. <br />M <br />Specific Site Information: PART III <br />Tank No.: 2 Tank Capacityt D l Z �TtEQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank Content: Tank Age: 1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />I If operations unless appropriate rationale or restrictions arero videM <br />Other: <br />4. Type of Operation: �Q <br />5. Release History: <br />Evidence of leaks / soil contamination: C3YES FINO <br />Documented Groundwater contamination: ElYES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: °F (high ambient temp.) <br />C3Noise Sources: <br />C3Oxygen Deficiency: <br />E]Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />C3Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />Ieuuinment): <br />C3Other, specify <br />An ' ipated Biolo ' 1 Hazards: <br />,EVnakes sects -8 <br />Other/Unkno specify <br />111isonous Plants <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 />P <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C <br />afed Hat. <br />ty Glasses/goggles. <br />teel toed/shank shoes or boots. <br />ame retardant coveralls. <br />Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />Po -- <br />vest. <br />ay communication. <br />■E <br />PART IV - PLAN APPRO L / <br />Plan Prepared by: Date: �l� <br />Plan Approved by: V Date: <br />