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SITE HEALTH AND SAFETY PLAN <br />PART I <br />PART II <br />GENERAL SITE <br />FO/RMATII?Nn 1.' <br />�-tw)i j� �-r+ckc- <br />_ n <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: <br />1. Chemicals Hazards <br />Address: $M <br />S • iOre1w'- W <br />_ <br />CA 1SW6 <br />++ ,^, ,, LL <br />IeNWi 1OrTrLI/rl` <br />ElCareinoges: <br />Contact Person: <br />` <br />Jo^'�S �Abr <br />Phone No: 33-21 <br />❑ Corrosives: 1 <br />Sweeps Number: <br />Proposed Date of investigation/inspection: 'J 4,7"p8 <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation. ❑ UAR Investigation. <br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair. <br />❑ Tank/Pipe Removal. ❑ Re cavation. <br />❑ Installation of Borings / Monitoring Wells. <br />09 - <br />ii <br />3. Specific Site orrnation: <br />Tank No.: <br />Tank Capacity: <br />Tank Content Tank Age: <br />Other: <br />4. Type of Operation: 1) <br />5. Release History: <br />Evidence of leaks / soil contamination: ❑ YES ❑ NO <br />Documented Groundwater contamination: ❑ YES ❑ NO <br />Background and description of any previous investigation or incidence: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />® Heafor Cold Stress: `M OF (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />eauinment): <br />❑ Other, specify <br />7. Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <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 />❑ Explosives: dg �t <br />Flammables: M�ive 194,194,oro a.4 <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART IH <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for an <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <br />❑ Organic Vapor Analyzer. <br />❑ Other, specify. <br />If monitoring instruments are not used, rationale or activity / area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ElA ElB <br />1-ygqHard Hat. <br />95 Safety Glasses/goggles. <br />Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR <br />A/P cartridge: <br />Safety vest. <br />❑ Two-way communication. <br />❑ SCBA <br />PART IV -PLAN APPROVAL <br />Plan Prepared by: , • ,r,�I Date: " Z7 <br />Plan Approved by: `r"" Date: g� <br />