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SITE HEALTH AND SAFETY PLAN <br />PART <br />GENERAL SITE INFOR TION 1 - <br />1. Site Name: Ot.. oy'�+ � c <br />Address: 17333 L.O r GBh," ILIA <br />Contact Person: E K1y PKI C.L Phone No: <br />Sweeps Number: <br />Proposed Date of investigation/inspection: y'I Llot <br />2. Description and brief narrative of inspection activity: <br />❑ New UST installation. ❑ UAR Investigation. <br />❑ Tank Closure in Place. ❑ Tank/Pipe Repair, <br />F1Tank/Pipe Removal. u•'"�*tl <br />❑ Installation of Borings / Monitoring Wells. <br />3. Specific Site Information: <br />Tank No.: <br />Tank Capacity: <br />Tank Content: Tank Age: <br />Other: <br />4. Type of Operation: %41A) C1N <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 />'b A CAlve <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: (fire, explosions, <br />etc..): <br />❑ C nfined space entry: (explosions): <br />Heavy equipment (physical injury & trauma resulting from moving <br />eouinment): <br />❑ Other, specify <br />Anticipated Biolo cal Hazards: <br />Snakes Ld Insects Rodents <br />❑ Other/Unknown (specify): <br />❑ Poisonous Plants <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 />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />Chemicals Hazards <br />Carcinogens: <br />❑ Corrosives: <br />ZDusts: <br />❑,Explosives: <br />Ey!Flammables: <br />❑ Inorganic 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 />El Safety Glasses/goggles. <br />Ur!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 />o <br />Plan Prepared by: 1 ' I I" r'1 �� Date: o <br />Plan Approved by: Date: <br />