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%move *4004 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: J ayi L ai h A14C3 /t_ - 1. Chemicals Hazards <br /> Address: 16,30 lot hay hn ❑Carcinogens: <br /> Contact Person: tZCLt If Phone No: Corrosives: <br /> Sweeps Number: Dusts: <br /> Proposed Date of investigation/inspection: ❑ Explosives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. <br /> ❑Tank Closure in Place. ❑Metals: <br /> ❑TanWPipe Repair ❑Oxidizers: <br /> ❑TanWPipe Removal. rr�`-' tM ISS <br /> ❑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: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation:�N.'C ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: <br /> [I Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO E]Other,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 Hat. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) ❑Safety Glasses/goggles. <br /> .Noise Sources: $�Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Hearing protection. <br /> C3Handling and Transfer of a Hazardous Substance:(fire,explosions, [I Tyvek. <br /> etc..): ❑Respirator: [3 APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): 7-Two-way communication. <br /> Cl Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes El insects ❑Rodents ElPoisonous Plants <br /> Plan Prepared by: II/1 /JM Iyw Date: <br /> E]Other/Unknown(specify): <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />