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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> �,n <br /> 1. Site Name: P(rGO , r I P 1. Chemicals Hazards <br /> Address: C I DD S M q,w, (:;;T 'Carcinogens: <br /> Contact Person: Phone No: g y <br /> ❑Corrosives: <br /> Sweeps Number. ❑Dusts: <br /> Proposed Date of investigation/inspection: 3( 1 I t 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. ❑Tank/Pipe a Rnepair. <br /> }ja2d o�.Uy t IV F1 PCB's: <br /> ❑Oxidizers: <br /> ElTank/Pipe Removal. <br /> [3 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 /> ff ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: (A Cl ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: El YES [3NO El Other,specify. <br /> Documented Groundwater contamination: [3 YES F1 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 /> Physical Concerns:(check all that apply&describe) ❑Hard Hat. <br /> F]Hear or Cold Stress: °F(high ambient temp.) El Safety Glasses/goggles. <br /> f-1 Noise Sources: Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> C]Excavation: <br /> Hearing protection.Excavation:(falls,trips,slipping,cave-ins): _ <br /> ❑ <br /> F-1Handlingand 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 PSafety vest. <br /> equipment): Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: �n, y <br /> [I Snakes sects El Rodents ❑Poisonous Plants Plan Prepared by: G>� IV*'��� Date: SCJ � <br /> ❑Other/LTnknown(specify): <br /> Plan Approved by: �� Date: I ' <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 />