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SI'Z'E HEALTH AND SAFETY PLAN <br /> All of the following must be completed. If a different Site Safety Plan is submitted, that Plan must include the <br /> following information: <br /> I. GENERAL SITE INFORMATION <br /> Site Name: f ovA-0n (.I W5r_b� _T_12 <br /> Site Address: lZ tiIc [AArwna L41.1A <br /> Contact Person: (/ ,Jw F-'O" Phone: (,,it, ) 'lv i — zc-if. <br /> Site Identification Number Proposed Date(s) of Site Work: io L za,U t <br /> II. DESCRIPTION OF INSPECTION ACTIVTTY <br /> Purpose of Activity: Type of Site: <br /> ❑ Monitoring well installation ❑ Industrial <br /> ❑ Gas extraction well installation ❑ Gas station <br /> ❑ Domestic well installation ❑ Landfill <br /> ❑ Agricultural well installation Other (specify): <br /> Other (specify): STwL. <br /> Provide a brief description of the proposed activities: <br /> I, I>a...:. Gca'.-.5$ (,rL z' �� 1/�.t-.c vs gpM'°J a fa ti CA+vi.9triN wrTn� 4xM� <br /> Investigation-derived material disposal: <br /> Soil: �✓A <br /> Water: <br /> Other: <br /> III. POTENTIAL HEALTH AND SAFETY HAZARDS <br /> Anticipated physical hazards. Check all that apply. <br /> ❑ heat (high ambient temperature) Heavy equipment <br /> ❑ cold ❑ physical injury/trauma resulting from moving machinery <br /> f9 noise <br /> ❑ oxygen depletion E General construction <br /> ❑ asphyxiation ES physical injury and trauma <br /> ❑ electrical hazards <br /> ❑ Excavation <br /> ❑ cave-ins ❑ Other (specify): <br /> ❑ falls, trips, slipping <br />