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Sp,N ]pp QUIN COUNTY NVIRONy1ENTAL HEALTH DI`/ISION <br /> SITEHEALTH AND SAFETY PLAN <br /> P.�RT II <br /> T I EVALUATION OF POT&`>TIAL fL1Z.4RDS <br /> SITE INFO&MATION <br /> Chemicals Hazards <br /> ice Name: () Carcinogens: <br /> ddress: l �t 6 Corrosives: <br /> ontact Person Phone No Dusts: <br /> weeps Number. ( ] Explosives: <br /> ectton• (] plammables: <br /> ;oposed Date of investiganon/uup ��- <br /> [ ) Inorganic Gases: <br /> Description and brief narrative of inspection acdvitr (] Mecals• <br /> UAR Investigation [) o ddizers: <br /> ( ] Ne�v UST [nstalladon ( ) Tank/Pipe Repair <br /> ( ] T,ank Closure in Place [ l [] PCB's• <br /> nim Re•escavadon <br /> `Y `ank/Pioe Removal [ ] a Wells[ J Installation of Borings/Monitoring PART III <br /> REQUIRED PERSONAL PROTECTIVE <br /> Specific Sice Information: EQUIPW_NT <br /> Tank No. Tank Capacity �eT—S <br /> Q Tank Ag : Equipment: (note: Monitoring <br /> Tank Contents: rtonicoring E4 P <br /> Other- instruments must be used for all operations <br /> n� /In���� unless appropriate rationale or restrictions are <br /> Type of Operation• provided) <br /> [ ] Combusnble Gas/Oxygen , lever <br /> Release History: [] Detector Tubes (Specify)�— <br /> Eridence of Leaks/soil contamination: [ ) `SES [ 0 ( ] Phatoionization Detector ---- <br /> Evidence <br /> Groundwater concaminanon: [ ) �� [ NO or: <br /> Vapor Analyzer Background and description of any previous nves�iga�ion [ ) other, specify: <br /> or incidence: if monitoring instruments are not used, <br /> rationale or activity/area restrictions' <br /> Pocential'Health and Safety <br /> Physical Concerns: (check all that apply esc-bambient temp.)) <br /> [ ] Heat or Cold Stress: (high 2. Personal Protective Equioment <br /> [ ) Noise Source: Level of Protection: ( ]A [ ]B [ )C [ ]D <br /> ( ] Oxygen Deficiency* ( ] Hard hat <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins)_,_ ( ] Safety glasses/goggles <br /> ( ] Handling and Transfer of a Hazardous Substance: ( ] Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) [ ] Flame retardant coveralls <br /> [ ] Confined Space entry: (explosions)------- � [] Hearing protection <br /> ( ) Heavy equipment (physical injury & trauma resulting [ ] Tyvek <br /> from moving equipment) [ ] Respirator, circle: APR or SCBA <br /> A/P cartridge: <br /> [ ] Other, specify [ ] Safety vest <br /> [ ] Two-way communication, <br /> Anticipated Biological Hazards: poisonous Plants <br /> ( J Snakes. [ ] Insects ( ] Rodents [ ) PART N <br /> ( ] Ocher/Unknown (specify): PLAN APPROVAL <br /> Narrative (provide all information which could impact Health plan prepared by: _ Dace: <br /> and Safety, e.g., power lines, incegriry of dikes, regain, ecc.): <br /> Plan Approved by: Date: <br /> 12 <br />