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Sc1,N JOAQUIv C014 ENVIROMMENTAL HEALTH ISION <br /> SITE HEALTH AND SAFETY PLAN <br /> kRT I PART II <br />:NERAL.SITE INFORMATION EVALUATION OF POTEN'T'IAL HAZARDS <br /> Site Name: 1. Chemicals Hazards <br /> Address: [] Carcinogens: <br /> Contact Person: Phone No. [] Corrosives: <br /> Sweeps Number. [ J Dusts: <br /> Proposed Date of investigation/inspecdon: [ J Explosives: <br /> [] Flammables• <br /> Description and brief narrative of inspection activity: [ ] Inorganic Gases: <br /> [ ] New UST Installation [ j UAR Investigation 1: [j Metals: <br /> ( j Tank Closure in Place [ j Tank/Pipe repair [ J Oxidizers: <br /> ( j Tank/Pipe Removal [ j Re-excavation [J PCB's: <br /> ( j Installation of Borings/Monitoring Wells <br /> PART III <br /> Specific Site Information: REQUIRED PERSONAL•PROTECITVE <br /> Tank No. Tank Capacity: EQUIPMENTTank Contents: Tank Age: <br /> 1. Monitoring Equipment: (note: Monitoring <br /> Other: <br /> instruments must be used for all operations <br />. Type of Operation: unless appropriate rationale or restrictions are <br /> provided) <br />. Release History: ( ] Combustible Gas/Oxygen Meter <br /> Evidence of leaks/soil contamination: [] YES [ ] NO ( ] Detector Tubes (Specify) <br /> Documented Groundwater contamination: [ ] YES ( J NO [ ] Photoionization Detector _ <br /> Background and description of any previous investigation [] Organic Vapor Analyzer <br /> or incidence: ( ] Other, specify: <br /> If monitoring instruments are not used, <br /> rationale or activity/area restrictions: <br />. Potential Health and Safety <br /> Physical Concerns: (check all that apply&describe) <br /> [ J Heat or Cold Stress: OF (high ambient temp.) 2. personal Protective Equipment <br /> [ J Noise Source: <br /> [ ] Oxygen Deficiency: <br /> Level of Protection: [ jA [ ]8 ( ]C [ ]D <br /> ( ] Excavation: (falls, trips ,slipping, cave-ins) [ ] Hard hat <br /> [ ] Handling and Transfer of a Hazardous Substance: [ j Safety glasses/goggles <br /> (fire, explosions, etc.) [ ] Steel toed/shank shoes or boots <br /> ( j Confined Space entry: (explosions) [ ] Flame retardant coveralls <br /> ( ] Heavy equipment (physical injury& trauma resulting [ ] Hearing protection <br /> from moving equipment) [ ] Tyvek <br /> [ j Respirator, circle: APR or SCBA <br /> ( j Other, specify A/P cartridge: <br /> ( ] Safety vest <br /> T. Anticipated Biological Hazards: ( ] Two--way communication <br /> ( J <br /> Snakes,- [ ] Insects [ ] Rodents [ ] Poisonous Plants PART IV <br /> ( j Other/Unknown (specify): PIAN APPROVAL <br /> B. Narrative (provide all information which could impact Health <br /> and Safety, e.g., power lines, integrity of dikes, terrain, etc.): Plan Prepared by: Date: <br /> Plan Approved b'y:' Date: <br /> 22 <br /> I <br />