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SA<v JOAQUI SCITOU N D S( ETIHEALTH Z, PLANHEALTH DIVISION <br /> PART II <br /> l EVALUATION OF POT&`nZAI- HAZARDS <br /> SITE INFOWMATION <br /> Chemicals Hazards <br /> to Name: �t [] Carcinogens: <br /> dress. l phone N . �y(pt) (] Corrosives: <br /> ntact Person* [ ] Dusts: <br /> eeps Number. 1S(oS� — [ ] Explosives: <br /> oposed Date of invesHgacion/usspecaon: [I Flammables: <br /> ( ] Inorganic Gases: <br /> escription and brief narrative of inspection activity [] Metals: <br /> ] New UST Inscalladon [ ] UAR Invescigadpn [ ] O;ddizers: <br /> Tan <br /> ] k Closure in Place [ J k/Pipe Repair (] PCB's: <br /> Tank/Pipe Removal [ ] Re•e ccavadon <br /> Wells <br /> j Installation of Borings/Mon icorin,v PART III <br /> PEFLSONAL PROTECTIVE <br /> REQUIRED <br /> oeci£ic Sice Info rs�tadon: 2 Fl/�/� EQUIPMENTank No. %i Tank Capacity: _5_29 <br /> ank Contents: Y Tank Age: _ L'S 1. Monitoring Equipmenc: (note: Monitoring <br /> thee_ insm:mencs must be used for all operations <br /> unless appropriate rationale or rescrictions are <br /> Type of Operation: } provided) <br /> [ J Combustible Gas/Oxygen Meter <br /> Release History: ,SES (�NO [ ] Detector Tubes (Soecify)�— <br /> Evidence of leaks/soil concaminadon: [ J / ( ]f S phocoionization Detector <br /> Documented Groundwater contamination: [ ] (� AVO (] Organic Vapor Analyzer�--- <br /> Background and description of any previous investigation ( I ocher, specify <br /> or incidence: If monitoring insaumenrs are not used, <br /> rationale or activity/area resu ccions: <br /> Pocencial'Healch and Safety <br /> Physical Concerns: (check all that apply h amcribe)temp.) <br /> [ J Heat or Cold Stress: of Chrg 2. Personal Protective Equipment <br /> [ ] Noise Source: Level of Protection: [ ]A [ ]B [ ]C [ ]D <br /> ( ] Oxygen Deficiency: ( ] Hard hat <br /> [ ] Excavation: (falls, trips ,slipping, cave-ins) _ ( I Safety glasses/goggles <br /> I ] Handling and Transfer of a Hazardous Substance: I ] Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) ( J Flame retardant coveralls <br /> [ I Confined Space envy: (explosions)— ( I Hearing protection <br /> ( ] Heavy equipment (physical injury & trauma resulting ( I Tyvek <br /> from moving equipment) ( J 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 /> [ ] Snakes;• [ ] Insects ( ] Rodents [ ] PRT IV <br /> ( ] Ocher/Unknown (specity): PLAN APPROVAL <br /> Narrative (provide all information which could impact Health Plan Prepared by: Date: <br /> and Safety, e.g., power lines, integrity of dikes, certain, etc.): <br /> Plan Approved by: _ Dace: <br /> 12 <br />