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SITE HEALTH AND SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />I. Site Name: <br />Address: <br />Contact Person: Phone No: <br />Sweeps Number: <br />Proposed Date of investigationlinspection: OatX; �;- <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 />3. pecific Site Information: <br />Tank No.: Tank Capacity: _ <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Chemicals Hazards <br />1' ❑ Carcinogens: <br />4 Corrosives: LViLOA <br />❑ Dusts: <br />❑ Explosives: <br />_'�aFlammables: <br />p❑'Inetal Inorganic as: -- s <br />etals: I� <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />Tank Content: Tank Age: 1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />Other: operations unless appropriate rationale or restrictions are provided) <br />M � ,t � " n <br />El Combustible Gas/Oxygen Meter. <br />4. Type of Opemtion:I C41ddL1alt,�,� �GjA,(` � ❑ Detector Tubes (Specify). <br />�J ❑ Photo ionization Detector. <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 />❑ Hear or Cold Stress: OF (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />❑ Handling and Transfer of a Hazardous Substance: (fire, explosions, <br />etc..): <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 ❑ Poisonous Plants <br />❑ Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health and Safety, <br />c s.. power lines, integrity of dikes, terrain, etc i <br />EII 2,3iN1 (12/17/2002) <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 ❑ C <br />❑ Hard Hat. <br />❑ Safety Glasses/goggles. <br />/Ej Steel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />❑ Hearing protection. <br />❑ Tyvek. <br />❑ Respirator. ❑ APR ❑ SCBA <br />A/P cartridge: <br />❑ Safety vest. <br />❑ Two-way communication. <br />PART IV - PLAN APPROVAL( �{ ? <br />Plan Prepared by. ./1 "—Date: <br />^ <br />Plan Apprurcd by: 1 `U \ Date: <br />