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SITE HEALTH AND SAFETY PLAN <br />PART <br />GENERAL SITE INFORMATION <br />1. Site Name: -7 f5D RA 8fl4WAE FWED/ 811W <br />Address: SSG H hhJ PPrIC% L - T1 <br />Contact Person: V-LM4" p1' I Phone No: 14IC ao 66 <br />Sweeps Number. <br />Proposed Date of investigation/inspection: 15(11, log <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. ❑ Hw <br />❑ Installation of Barings / Monitoring Wells. <br />'3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: Tank Age: <br />4. Type of Operation: 5 .SO 14 VtW F PftlkLA YL1 <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: °F (high ambient temp.) <br />❑ Noise Sources: <br />❑ Oxygen Deficiency: <br />❑ Excavation: (falls, trips, slipping, cave-ins): <br />[Handling and Transfer of a Hazardous Substance: (Bre, explosions, <br />Hc_l: <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 dinsects ❑ Rodents <br />[POther/Unlmown (specify): <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />GKarcinogens: <br />[Corrosives: <br />❑ Dusts: <br />5?txplosivM: <br />�lammables: <br />R'lu <br />organic Gases: <br />❑ Metals: <br />❑ Oxidizers: <br />❑ PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br />1. Monitoring Equipment (note: Monitoring instruments must be used for all <br />operations unless appropriate rationale or restrictions are provided) <br />❑ Combustible Gas/Oxygen Meter. <br />❑ Detector Tubes (Specify). <br />❑ Photo ionization Detector. <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 ❑ D <br />❑ Hard Hat. <br />&Kafety Glasses/goggles. <br />94teel toed/shank shoes or boots. <br />❑ Flame retardant coveralls. <br />❑ Hearing protection. <br />❑ Tyvek. <br />❑ Respirator: ❑ APR ❑ SCBA <br />AR' cartridge: <br />❑ Safety vest. <br />[I Two-way communication. <br />PART IV - PLAN APPROVAL1 <br />C] Poisonous Plants Plan Prepared by: & - AM" Date: - 16r! <br />Plan Approved by: <br />8. Narrative (provide all information which could impact Health and Safety, <br />e.g., power lines, integrity of dikes, terrain, etc.) <br />EH 23081 (12/17/2002) <br />Date: <br />