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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORM nTION p i, EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: /1� I p�,��lLk <br /> 1. Chemicals Hazards <br /> Address: 3 2 J PrR <br /> ®Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: (Dusts: <br /> Proposed Date of investigation/inspection: t o El Explosives: <br /> Flammables: <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. lren. ❑PCB's: <br /> r-1Installation of Borings/MonitormI lHells�y"f <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 /> Other: operations unless appropriate rationale or restrictions are provided) <br /> -7�,,� pp ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: I r "G�IC�wh ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO EJ 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 /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ❑D <br /> ❑Hard Hat. <br /> Physical Concerns:(check all that apply&describe) <br /> Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> ®Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Oxygen Deficiency: F-1 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 [ISCBA <br /> etc ): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> [Heavy equipment(physical injury&trauma resulting from moving 'tel Safety vest. <br /> equipment): ',Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> Snakes [Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: N Date: O <br /> ❑Other/Unknown(specify): ' _I <br /> Plan Approved by: kAA Date: to <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 />