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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: 1061 Y S- 1. Chemicals Hazards <br /> Address: Oa <br /> �c;arcinogens: <br /> Contact Person: 14 S Lb" (N1n/1 Phone No: ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: explosives: <br /> Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑, ipe Repair. ❑Oxidizers: <br /> C3Tank/Pipe Removal. . n. ❑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 /> \ E]Combustible Gas/Oxygen Meter. <br /> �y�� <br /> 4. Type of Operation: am �I ��1 1 o-�J c UUT l ❑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 /> 4 <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety 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 /> F1 Noise Sources: ,,_,� <br /> l�steel toed/shank shoes or boots. <br /> El retardant coveralls. <br /> El Oxygen Deficiency: <br /> [I Hearing protection. <br /> [3Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ,❑Safety vest. <br /> L1 <br /> equipment): YiSawo-way communication. <br /> 0 Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biolo al Hazards: <br /> ❑Snakes Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: Date: <br /> ❑Other/Unknown(specify): f, . <br /> Plan Approved by: �^ Date: J <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 />