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SITE HEALTH AND SAFETY PLAN <br /> Complete all the following information. <br /> If a different Site Safety Plan is submitted, that Plan must included the following information: <br /> GENERAL SITE INFORMATION <br /> NAME: ti ousf cd C <br /> SITE ADD C" ' IS o-i3`I " 3 ✓Q "O, Q �lG <br /> CONTAGIT <br /> \ P T PHONE : <br /> Z5-2LI 3—(o(P 0 2 <br /> SITEIDENTIFICATION#: PROPOSED DATED F E W RK: <br /> DESCRIPTION OF INSPECTION ACTIVITY <br /> Purpose of Activity Type of Site <br /> ❑ Monitoring well installation ❑ Industrial <br /> ❑ Gas extraction well installation ❑ Gas Station <br /> ❑ Domestic well installation ❑ Landfill l <br /> ❑ Agricultural well installation ' n `6 Other (specify) L G�SC7�WUX <br /> Other(specify) Q�V��f if rM 1�� <br /> Provide a brief description of the proposed activities: D1ri I(ap, Q,d M,<, 6D b6 y �- <br /> 3 <br /> Qty(I line nV Qft, a 12rff►[AS t 6 Q . <br /> Investigation derived material disposal: Soil x Water Other <br /> 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 /> Noise ❑ General construction <br /> ❑ Oxygen depletion �4 Physical injury and trauma <br /> ❑ Asphyxiation ❑ Electrical hazards <br /> ❑ Excavation ❑ Other (specify) <br /> ❑ Cave-ins <br /> '-'/ Falls, trips, slipping <br />