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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION1 ( S EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: �^{-� <br /> ,Z � I-& � is Hazards <br /> Address: <br /> ®Carcinogens: <br /> Contact Person: hone No: <br /> ❑Corrosives: <br /> Sweeps Number: <br /> _ � � ❑Dusts: <br /> Proposed Date of investigation/insp tion:_ ❑Explosives: <br /> ❑Flammables: oil filters,solvents a Q <br /> 2. Description and brief narrative of ins ection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑ AR Investigation. F1Metals: <br /> ❑Tank Closure in Place. ❑ ank/Pipe Repair. <br /> F1 Oxidizers: <br /> ❑Tank/Pipe Removal. ❑ e-excavation. ❑PCB's: <br /> ❑ Installation of Borings/Monitorin Wells. p <br /> 3. Specific Site Information: PART III <br /> Tank No.: ankCapacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: ank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: C1 cet- operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: Iko ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination ❑YES ❑NO [I Other,specify. <br /> Documented Groundwater contaminat n: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any pr ious investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B ❑C ® D <br /> Physical Concerns:(check all that appl i&describe) Z Hard Hat. <br /> ❑Hear or Cold Stress: (high ambient temp.) Z Safety Glasses/goggles. <br /> ❑Noise Sources: Z Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,c ve-ins): ®Hearing protection. <br /> ❑ <br /> ❑Handling and Transfer of a Hazard s Substance:(fire,explosions, Tyvek. <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: 7� / <br /> ❑Snakes ❑ Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: Jeffrey Wong Date: <br /> F1 Other/Unknown(specify): <br /> Plan Approved by: V"" Date: 1 <br /> 8. Narrative(provide all information whic could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,tem in,etc.) <br /> EH 23081(12/17/2002) <br />