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SITE HEALTH AND SAFETY PLAN <br />PART <br />GENERAL SITEfgFO MATI <br />1. Site Name: <br />Address: 10 S , —Lh1 i W CAQ zY <br />Contact Person: F GN Phone No: 11141 <br />Sweeps Number: <br />Proposed Date of investigation/inspection: <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 -excavation. <br />❑ Installation of Borings / Monitoring Wells. <br />�i k -L vka _ S ra <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. TypeofOperation: <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 />He+r Cold Stress: JV) °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, hips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />❑ Confined space entry: (explosions): <br />❑ Heavy equipment (physical injury & trauma resulting from moving <br />equipment): <br />❑ Other, specify <br />Anticipated Biological Hazards: <br />❑ Snakes ❑ Insects ❑ Rodents <br />❑ Other/Unknown (specify): <br />❑ Poisonous Plants <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 />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards j <br />18 Carcinogens: "ItaV^ <br />❑�, Corrosives: <br />�t9 <br />YDusts: <br />❑ Explosives: <br />Flammables P&VtA <br />❑ Inorganic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <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: ❑ A ❑ B <br />.® Hard Hat. <br />[� Safety Glasses/goggles. <br />ig Steel toed/shank shoes or boots. <br />❑q Flame retardant coveralls. <br />I^J' Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: <br />W, A/P cartridge: <br />LI Safety vest. <br />■ (r <br />❑ APR ❑ SCBA <br />❑ Two-way communication. <br />PART IV - PLAN APPROVAL <br />Plan Prepared by: Date: 8 ( -66 <br />Plan Approved by: *41u i Date: 7I1 lsz <br />