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SITE HEALTH AND SAFETY PLAN PART I PART H GENERALS] INFORMATION /rfr y//',�, �```'''��, EVALUATION OF POTENTIAL HAZARDS 1. Site Name: �� (yC„ •J. �'t -�( .�—t ^knnis-Is Harsrds Address: 913A V1� 1C - 1 „^ ® Carcinogens: a'" /,(1 . © r Contact Person: Phone No: / 3 ❑ Corrosives: Sweeps Number: Proposed Dale of investigation/inspection: _ 2. Description and brief narrative of inspection activity: ❑ New UST installation. ❑ UAR Investigation. ❑ Tank Closure in Place. ❑ Tank/Pipe Repair. ❑ Tank/Pipe Removal. ❑ Re -excavation. ❑ Installation of Borings / Monitoring Wells. 3. Specific Site Information Tank No.: Tank Capacity: Tank Content: Tank Age: Other: 4. Type of Operation: �✓ �xi.�QS f✓ie1 5. Release History: Evidence of leaks / soil contamination: ❑ YES ❑ NO Documented Groundwater contamination: []YES ❑ NO Background and description of any previous investigation or incidence: 6. Potential Health and Safety Physical Concerns: (check all that apply & describe) ❑ Hear or Cold Stress: OF (high ambient temp.) ❑ Noise Sources: ❑ Oxygen Deficiency: ❑ Excavation: (falls, trips, slipping, cave-ins): ❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, etc..): ❑ Confined space entry: (explosions): ❑ Heavy equipment (physical injury & trauma resulting from moving ❑ Other, specify Z Anticipated Biological Hazards: ❑ Snakes ❑ Insects ❑ Rodents ❑ Poisonous Plants ❑ Other/Unknown (specify): 8. Narrative (provide all information which could impact Health and Safety, e.g., power lines, integrity of dikes, terrain, etc.) EH 23081 (12/17/2002) ❑ Dusts: ❑ Explosives: 'V �l ❑ Flammables: oil filters. solvents ❑ Inorganic Gases: Cl Metals: ❑ Oxidizers: ❑ PCB's: PART III REQUIRED PERSONAL PROTECTIVE EQUIPMENT 1. Monitoring Equipment (note: Monitoring instruments must be used for all operations unless appropriate rationale or restrictions are provided) ❑ Combustible Gas/Oxygen Meter. ❑ Detector Tubes (Specify). ❑ Photo ionization Detector. ❑ Organic Vapor Analyzer. ❑ Other, specify. If monitoring instruments are not used, rationale or activity / area restrictions: 2. Personal Protective Equipment Level of Protection: ❑ A ❑ B ❑ C Z D ® Hard Hat. ® Safety Glasses/goggles. Z Steel toed/shank shoes or boots. ❑ Flame retardant coveralls. ® Hearing protection. ❑ Tyvek. ❑ Respirator: ❑ APR A/P cartridge: ® Safety vest. ❑ Two-way communication. ❑ SCBA PART IV - PLAN APPROVAL Plan Prepared by: Jeffre W Date: X_ Date: ,7 Plan Approved by: