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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION p/� EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1'- O /"1 I. Che 'cals Hazards <br /> r <br /> Address: C ogens: <br /> Contact Person: hone No: osives-. <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection:-4q( Explosives: <br /> ammables: <br /> 2. Description and brief narrative of inspection activity: <br /> ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑ Inslallation of Borings/Monitoring Wells. <br /> '3. S'ecific 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 /> ❑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: <br /> ❑YES ❑NO ❑mer'specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES F1 NO <br /> Background and description of any previous investigation or incidence: <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) ardat. <br /> Oaifet�Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) toed/shank shoes or boots. <br /> ❑Noise Sources: 1/' <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> ❑ Excavation:(falls,trips,slipping,cave-ins): [I Hearing protection. <br /> C]Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑Tyvek. <br /> etc..): ❑Respirator: ❑APR ❑ SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving aPq <br /> fety vest. <br /> equipment): P4wo-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPRO AL <br /> 7. Anticipated Biological Hazar /0 <br /> E]Snakes E]Insects odents ❑Poisonous Plants Plan Prepared by: Date: <br /> ;/ <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: � 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 />