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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: W(lagy,-1 W TI.YT.o 1. Chemicals Hazards <br /> Address: '1-2-1 ✓M S�p.�.I,�'rn..�. ❑Carcinogens: <br /> Contact Person:.3 G (A—J_rtA+V—Phone No: 6 out <br /> ❑Corrosive: <br /> Sweeps Number: <br /> [ busts: <br /> Proposed Dale of investigation/inspection: l In 10 <br /> � ❑Explosive: <br /> IX Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑'T�,aA1--n��k/��Pip��e�Rwee�pair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. M u6.6x�e�Xt T ❑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 must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: t�,w�'0 Y'eT�(Ah� ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑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 <br /> Level of Protection: ❑A ❑B ❑C ❑D <br /> Physical Concerns:(check all that apply&describe) ❑Hard Hat. <br /> ❑Hear or Cold Stress: °F(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 /> [IHandling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> eta.): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): AT cartridge: <br /> ❑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 Biological Hazards: w�1 �] nnI _ <br /> C]Stakes EA Insects (]Rodents C1 Poisonous Plants Plan Prepared by: ,` ' /" �UVV` Date: al�r o y <br /> ❑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 /> L <br />