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SSV JOAQUI`rSITETy EN'VIR0MENTAL�TH ANDM SAFETY <br /> p �I TH DIVIS]O v <br /> PART II <br /> T I EVALUATION OF POTENTIAL HALkRDS <br /> SITE INFORIMATION <br /> Pmt ltn� 1. ClXmicals Hazards <br /> ice Name: I fyY} Qh ( Carcinogens: <br /> ddress: t Nom' I Corrosives: <br /> ontactPerson Phone No ]'t(��J4 �� u: <br /> weeps Number. ~ooives: <br /> n/mspecnon: mmables <br /> : <br /> roposed Date of nvestigati <br /> ecdon activity: ( ] Inorganic Gases: <br /> escrittion and brief narrative of insp (] Metals: <br /> UAR Investigation [ ] O,ddizers: <br /> ] New UST Installation ( ] Tank/Pi a Repair <br /> ] ank Closure in Place [ ] p (]PCB's: <br /> ank/Pipe Removal ( ] Re-excavation <br /> ] Installation of Borings/Monitoring Wells PART III <br /> REQUIRED PERSONAL PROTECTIVE• <br /> Specific Sice Information: EQUIPMENT <br /> Tank Na. Tank Capacity: �D <br /> Tank Contents: !!9 Tank Age: 5 1. Monitoring Equipment: (note: Monitoring <br /> Other: instruments must be used for all operations <br /> M � unless appropriate rationale or restrictions are <br /> Type of Operation: p ' ed) <br /> (ro Combustible Gas/Oxygen Meter <br /> Release History ( 1 Detector Tubes (Soecify)�_ <br /> Evidence of leaks/soil contamination: [ ] �� O ( ] ohocoionization Detector�— <br /> Documented Groundwater contamination: [ ] YES [� O (] Organic Vapor Analyzer�— <br /> Background and description of any pre investigation [ ] Other, specify' <br /> or incidence: If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br /> Pocential'Health and Safety <br /> Phyy{cal Concerns: (check all that apply & describe) <br /> [ rieac or Cold Stress: °E (high ambient temp.) . . /. <br /> 2. Personal Protective Equipment <br /> ( ] Noise Source: Lao of Protection: [ ]A [ ]B ( ].C <br /> ( ] g.1 Deficiency: ��d hat <br /> [cavation: (falls, trips ,slipping, cave-ins) (tf Ears' glasses/goggles <br /> ( Handling and Transfer of a Hazardous Substance: [ Steel toed/shank shoes or boots <br /> (fire, explosions, etc.) [ ] Flame retardant coveralls <br /> ( j nlined Space entry: (explosions) [ ] Hearing protection <br /> [i}�rHeavy 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 /> Anticioaced Biological Hazards: poisonous Plants <br /> [ ] <br /> Snakes,- ( ] Insects [ ] Rodents ( l PART IV <br /> ( ] Other/Unknown (specify): PLAN APPROVAL <br /> Narrative (provide all information which could impact Health plan Prepared by: J Dace: <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br /> Plan Approved by: _ � Date: <br /> ---------------- <br /> 12 <br />