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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: W1 ED td D• &d" KD 1. Chemicals Hazards <br /> Address: tau <br /> 9 93 Carcinogens: <br /> Contact Person: �+ r aa� Phone No: 9 3�-1 S 7 <br /> ❑Corrosives: <br /> Sweeps Number: F]Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> *M Flammables: <br /> 2. Description and brief narrative of inspection activity: ❑ Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> PART III <br /> 3. Specific Site formation: <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> l [I Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: <br /> uP v ❑Detector Tubes?Specify). <br /> ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination: El YES [I NO <br /> Documented Groundwater contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C ❑D <br /> 6. Potential Health and Safety <br /> Hard Hat. <br /> Physical Concerns:(check all that apply&describe) <br /> Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> �j Steel toed shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: <br /> �Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, El APR ❑SCBA <br /> etc..): ❑Respirator: <br /> A/P <br /> ElConfined <br /> vest. <br /> Confined space entry:(explosions): cartridge: <br /> El Heavy equipment(physical injury&trauma resulting from moving Safety <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: {� <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: 4wLDate: �7�Qfi <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: <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 />