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ii <br />1.i�•� 0 � <br />1 P <br />PART I <br />GENERAL SITE INFORMATION <br />1. <br />Site Name: <br />Address: <br />Contact Person: Phone No. <br />Sweeps Number. <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity. <br />[ J 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. Specific Site Information: <br />Tank No. <br />Tank Contents: <br />Other: <br />4. Type of Operation: <br />Tank Capacity: <br />Tank Age: <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 <br />or incidence: <br />A <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[) Heat or Cold Stress: of (high ambient temp.) <br />[ ] Noise Source: <br />[ J Oxygen Deficiency: <br />[ ] Excavation: (falls, trips ,slipping, cave-ins) <br />[ ] Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] Confined Space entry: (explosions) <br />[ ] Heavy equipment (physical injury & trauma resulting <br />from moving equipment) <br />[ ] Other, specify <br />7. Anticipated Biological Hazards: <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />[ ] Other/Unknown (specify): <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />EH23081 (2/7/92) <br />PART H <br />EVALUATION OF POTENTIAL HAZARDS <br />1. <br />Chemicals Hazards <br />[ ] <br />Carcinogens: _ <br />(] <br />Corrosives: <br />[ J Dusts: <br />[ ] Explosives: <br />[ ] Flammables: _ <br />[) Inorganic Gases: <br />[ ] Metals: <br />[ J <br />Oxidizers: <br />[ ] PCB's: <br />PART III <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />[ ] Combustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ ] Photoionization Detector <br />[ J Organic Vapor Analyzer <br />[ ] Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Level of Protection: ( ]A [ ]B [ ]C [ JD <br />[ ] Hard hat <br />[ ] Safety glasses/goggles <br />[ ] Steel toed/shank shoes or boots <br />[ ] Flame retardant coveralls <br />[ J Hearing protection <br />[ ] Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />A/P cartridge: <br />[ ] Safety vest <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by- Date: <br />Plan Approved by: Date: <br />r: <br />