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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE It4FORMATION, EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: T Vs* 1. Chemicals Hazards `� <br /> Address: ��U Y H� 0l <br /> 3`1- 12 Carcinogens: <br /> Contact Person: PweL- Phone No: Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: <br /> ❑Explosives: <br /> Flamntables: it <br /> 2. Description and brief narrative of inspection activity: <br /> E3 Inorganic Gases: <br /> ❑New UST installation. [3UAR Investigation. <br /> El Metals: <br /> ElTank Closure in Place. ElTank/Pipe Repair. <br /> El Oxidizers: <br /> ElTank/Pipe Removal. ❑Re-excavation. El PCB's: <br /> El Installation of Borings/Monitoring Wells. <br /> �3W ( PART III <br /> 3. Specific Site Inf tion: <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: <br /> operations unless appropriate rationale or restrictions are provided) <br /> � J <br /> [3 Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: � �� ��^^ 1 � ❑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: El YES F-1 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) [Nand Hat. <br /> ❑Hear or Cold Stress: OF(high ambient temp.) [}Safety Glasses/goggles. <br /> ❑Noise Sources: ❑Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: aF1ame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): aHearing protection. <br /> ❑ <br /> El 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 I$afety 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 <br /> Plan Prepared by: Date: � <br /> ElOther/Unlmown(specify): <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081 (12/17/2002) <br />