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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: � N 1 1. Chemicals Hazards <br /> Address: 1'U0 S b, ^ [n Carcinogens:_ <br /> Contact Person: N) Phone No: -)-34 <br /> ❑Corrosives: <br /> Sweeps Number: <br /> [R Dusts: <br /> Proposed Date of investigation/insp tion: `�'S �Q <br /> ❑Explosives: <br /> ®Flammables: <br /> 2. Description and brief narrative of in ection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑ AR Investigation. <br /> ❑Metals: <br /> ❑Tank Closure in Place. ❑ ank",/ Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑ e-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monito ' Wells. <br /> 3. Specific Site rmation: PART III <br /> Tank No.: I ank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contaminIf monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any pat n: El El NO ious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety <br /> Level of Protection: ❑A ❑B ❑C [aD <br /> Physical Concerns:(check all that appl i&describe) ©Hard Hat. <br /> n Heakor Cold Stress: (high ambient temp.) ®Safety Glasses/goggles. <br /> El Noise Sources: (Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,ca a-ins): CY Hearing protection. <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardo s Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> El Snakes [I Insects El Rodents E]Poisonous Plants /V6 <br /> Plan Prepared by: Date: <br /> ❑Other/Unknown(specify): <br /> 8. Narrative(provide all information which could impact Health and Safety, Plan Approved by: Date: <br /> e.g.,power lines,integrity of dikes,terra n,etc.) <br /> EH 23081 (12/17/2002) <br />