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0 0 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: A e ,,,1 1. Chemicals Hazards <br /> Address: 41-i I RtJ y1,fiL� Ny carcinogens: <br /> Contact Person: ,iMS Phone No: 9W�-370 L ❑Corrosives: <br /> Sweeps Number: ,,.1 ❑Dusts: <br /> Proposed Date of investigation inspection: X 1Ad I O ❑Explosives: <br /> �qFlammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ,❑TTan�k(Pipe Repair. E]Oxidizers: <br /> ❑Tank/Pipe Removal. I�yStC+ae .� ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments most be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other <br /> {��A�^���-�x 7� � .�,( g��� p-�/�' l ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:�I ' DAI r r L�1' p/ii(N ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: <br /> El Organic Vapor Analyzer. <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑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 ❑Hard Hat <br /> Physical Concerns:(check all that apply&describe) <br /> 'Rf Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) 'pl Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ❑Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Respirator: ❑APR ❑SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> AHcavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): '93Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes 5TJnsects ❑Rodents ❑Poisonous Plants Plan Prepared by: f/1^ , N F)'/ Date: <br /> ❑Other/Unknown(specify): I <br /> Plan Approved by: � /c <br /> Date: '6'�!(•(9 <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 />