Laserfiche WebLink
0 0 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION �l EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: rl:1n.U/ .�/�✓��A'V+ �q8 1. Chemicals Hazards <br /> Address: /� pb 4'V'v . �`( W !,C Carcinogens: <br /> Contact Person: llPhone No: ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation inspection: Explosives: <br /> 2. Description and brief narrative of inspection activity: V Inorganic Gases: <br /> ❑New UST installation. ❑UAR investigation. ❑Metals: <br /> ❑Tank Closure in Place. �❑t,Tank/Pipe Repair. /.., ❑Oxidizers: <br /> ❑Tank/Pipe Removal. Y-" hOn. 7n.,.(,�p,t,t,A �f°M- ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. T <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 /> Oche operations unless appropriate rationale or restrictions are provided) <br /> C3 Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: 44 S ❑Detector Tubes(Spmify). <br /> ❑Photo ionization Detector. <br /> S. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑pec'specify. <br /> Documented Groundwater contamination: El YES NO <br /> If monitoring instruments are not used,rationale m activity/area restrictions: <br /> ❑ <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Pmtmtion: C1 ❑B ❑C [ID <br /> 6. Potential Health and Safety <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 /> ❑Flame retardant coveralls. <br /> Oxygen Deficiency: <br /> Heating protection. <br /> C]Excavation:(falls,trips,slipping,cave-ins): ❑ <br /> (3 Handling and Transfer of a Hazardous Substance:(fire,explosionsResp <br /> , [I k. <br /> ❑Respirator: ❑APR C]SCBA <br /> eta.): <br /> 0 Confined space entry:(explosions): AT cartridge: <br /> ❑Heavy equipment(physical injury&hauma resulting from moving 'Safety vest. <br /> equipment): tpq�Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: ,,,/ <br /> ❑snakes �Insects ❑Rodents E]Poisonous Plants Plan Prepared by: r P1 0-t't Df-2-1(/ (0 <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: U11' Date: 12 1 p <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,termin,etc.) <br /> EH 23081(12/17/2002) <br />