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• NTAL HEALTH 'VISION <br /> S��`( IOAQUINSITE HEALTH AND SAFETY PLAN <br /> PART II <br /> RT [ EVALUATION OF POTENTIAL HAZARDS <br />-YEFLIL <br /> SITE INFORMATION <br /> 1. Chemicals Hazards <br /> Site Name: G S ��` 1� 7 <br /> ' 1[] Carcinogens: <br /> Address: �� one No. 6 O [] Corrosives: <br /> Contact Person: [ ] Dusts: <br /> Sweeps Number. [ ] Explosives: <br /> Proposed Date of in esri acion/inspection: [] Flatrmrables: <br /> ( j Inorganic Gases: <br /> Description and brief narrative of inspection activity: ( ] Metals: <br /> [ ] New UST Installation [ ] UAR Investigation Metals: <br /> ( tk Closure in Place ( ] Tank/Pipe Repair PCB's: <br /> Tank/Pioe Removal [ ] Re-excavation <br /> [ J Installation of Borings/Monitoring Wells PART III <br /> REQUIRED PERSONAL PROTECTIVE <br /> Specific Site Information: EQUIPMENT <br /> Tank No. t>L 2— Tank Capacity: /7 <br /> Tank Contents: 2 Tatrk Age' Equipment:menr. (note: Monitoring <br /> 1. Monitoring Eq P <br /> Other: instruments must be used for all operations <br /> unless appropriate rationale or restrictions are <br /> Type of Operation: provided) <br /> [ ] Combustible Gas/Ox/gen Meter <br /> Release History: YES [ ] NO [ ] Detector Tubes (Specify)_ <br /> Evidence of leaks/soil contamination: ( ] photoionization Detector <br /> Documented Groundwater contamination: [ ] YES ( ] [ ]Organic Vapor Analyzer o— <br /> Background and descriodon of any previous Investigation <br /> Othier, specify: <br /> P ify: <br /> or incidence: If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> Pocential*Health and Safety <br /> Physical Concerns: (check all that apply & descnbe) <br /> [ J Heat or Cold Stress: of (high ambient temp.) <br /> 2 Personal Protective Equipment <br /> ( ] Noise Source: Level of Protection: [ ]A ( ]B [ JC D <br /> [ J Oxygen Deficiency rx Hard hat <br /> ( J Excavation: (falls, trips ,slipping, cave-ins) "Safety glasses/goggles <br /> [ ] Handling and Transfer of a Hazardous Substance: n�Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) ( ] Flame retardant coveralls <br /> ( ] Confined Space entry: (explosions) Hearin <br /> [ ] Heavy equipment (physical injury& trauma resulting ( ] g protection <br /> Tyv <br /> from moving equipment) ( ] <br /> [ Respirator, circle: APR or SOBA <br /> A/P cartridge: <br /> [ J Other, specify [ ] Safety vest <br /> 7. Anticipated Biological Hazards: <br /> [ ] Two--way communication <br /> ( J Snakes• [ ] Insects [ ] Rodents [ ] Poisonous Plants PART N <br /> [ ] Other/Unknown (specify): PLAN APPROVAL <br /> 8. Narrative (provide all information which could impact Health Plan Prepared by Date: <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br /> Plan Approved by: Dace: <br /> 12 • <br />