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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: 'l 1. Chemicals Hazards <br /> Address: �7 Carcinogens: <br /> Contact Person:J Phone No: % Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of inveaigation/inspection: 4j 7� Explosives: <br /> KFlammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/PipeRepair. o �r7 C]Oxidizers: <br /> ❑Tank/Pipe Removal. �,iGba><&OTS I NDP /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: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> A/���`` en,�,., ��' E]Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: /'fc�l'rD /v.Glr'�� ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑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: C1 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) ❑Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) D tSteel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: ❑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 /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): w,Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: ,. �l -Awn <br /> ) 10 <br /> El Stakes Insects [I Rodents ❑Poisonous Plants Plan Prepared by:YV 1 P`r' ' QVIA Date: 7 <br /> ❑Other/Unknown(specify): <br /> II.1; ld <br /> Plan Approved by: VA Date: <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 />