Laserfiche WebLink
SITE HEALTH AND SAFETY PLAN <br />PART I�l�ttn�� C PART II <br />GENERAL SITE INFORM ATrn?,T EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: _ sf'DGk%hn 1 <br />Address: <br />Contact Person: Wrko.e No: (ZM) 3--A%0 <br />Sweeps Number <br />Proposed Date of investigation/inspection: t' po� l (� <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation. ❑ UAR Investigation. <br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. WMW".it. <br />❑ Installation of Borings /Monitoring Wells. <br />3. Specific Site Information: <br />Chemicals Hazards <br />Carcinogens: <br />Corrosives: <br />❑ Dusts: <br />❑ Explosives: <br />Flammables: <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank Content: Tank Age: l . Monitoring Equipment (note: Monitoring instruments must be used for all <br />Other: operations unless appropriate rationale or restrictions are provided) <br />"�_ ❑ Combustible Gas/Oxygen Meter. <br />4. Type of Operation: l CY rVw1 N �n T1G^,t �j� Q T7.� ❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />5. Release History: ❑ Organic Vapor Analyzer. <br />Evidence of leaks /soil contamination: <br />❑ YES ❑ NO ❑ Other, specify. <br />Documented Groundwater contamination: C] YES El NO If monitoring instruments are not used, rationale or activity / area restrictions: <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />❑ Hear or Cold Stress: °F (high ambient temp.) <br />�Ooise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />❑ Confined space entry: (explosions): <br />,Heavy equipment (physical injury & trauma resulting from moving <br />eauinment): <br />❑ Other, specify <br />Anticipated Biological Hazards: <br />❑ Snakes �4 Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <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 />2. Personal Protective Equipment <br />Level of Protection: ❑ A ❑ B ❑ C ❑ D <br />❑ Hard Hat. <br />[ Safety Glasses/goggles. <br />{ Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />❑ Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />A/P cartridge: <br />❑ Safety vest. <br />'Two-way communication. <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: m ' /J`91 /yam Date: <br />Plan Approved by: <br />Date: <br />