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SITE HEALTH AND SAFETY PLAN <br /> PART PART II <br /> GENERAL SITE <br /> 1. Site Name: */�` EVALUATION OF POTENTIAL HAZARDS <br /> (�� [ �- �l /G1}l,',"/�0`Y( I 61em:e-ls Hazards tf'` <br /> Address: f' Z �-Z � py� � // ®Carcinogens: <br /> Contact Person: Phone No: ✓ �" 6Tq(1❑Corrosives: � ( c -SO 0. Y/ <br /> Sweeps Number: ' <br /> fl�n <br /> sts: <br /> Proposed Date of investigation/inspection:_ lplosives: nJ <br /> blesoilfisolvents2. Description and brief nartative of inspection activity: rgniGasesElNew UST installation. ❑UAR Investigation. etals: PMIS <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Informanop PART III <br /> ryS� <br /> ank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other. AvV r D oe Q p M 4( operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: ❑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: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background an descrip on of any prev ous investigation or mci cc: <br /> ovru <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ®D <br /> rPhem :(check all that apply&describe) ®Hard Hat. <br /> C S s: °F(high ambient temp.) ®Safety Glasses/goggles. <br /> ources: ®Steel toed/shank shoes or boots. <br /> El Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ®Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> ❑Respirator: El APR C3SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P 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 `f <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes El Insects El Rodents El Poisonous Plants Plan Prepared by: Jeffrey Wong Date: <br /> ❑Other/Unknown(specify): J <br /> Plan Approved by: L Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.�t power lines,integri,�of�d,�ike,s,,t,��in',etc.) <br /> TAVbrn -7 <A <br /> EH 23081(12/17/2002) <br />