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PART <br />PART II <br />GENERAL SIM INFORMATION <br />EVALUATION OF POTENTIAL HAZARDS <br />1. <br />Site Name: A P ow, <br />1. Ch 'call Hazards <br />Address: n !� C4t.,6.:2 <br />W_CTC'1Z0`gens: <br />Contact Pers n: A Phone No. 9/b - y a13 <br />Corrosives: <br />Sweeps Number. 4 -et, Iq'k -s- <br />Proposed Date of mivestiga'don/inspecrion: <br />g5xplosives: <br />Cq/� Iarnmables: <br />2. <br />Description and brief narrative of inspection activity. <br />inorganic Gases: <br />New UST Installation UAR Investigation <br />Metals: <br />Tank Closure in Place Tank/Pipe Repair <br />Oxidizers: <br />t4lTevWPipe Removal Re -excavation <br />PCB's: <br />Installation of Borings/Monitoring Wells <br />PART M <br />3. <br />Specific Site Information:REQUIRED <br />PERSONAL PROTECTIVE <br />Tank No. V. J-Zo Tank &*p'aclir. <br />EQUIPMENT <br />Tank Contents: Tank Age: <br />Other: <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />4. <br />Type of Operation: <br />unless appropriate rationale or restrictions are <br />pro yv'ded) <br />S. <br />Release History- <br />(TCombusrible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: <br />Detector Tubes (Specify) <br />Documented Groundwater contamination: YES <br />Photoionization Detector <br />Saclicl-r-ound and description of any previous investigation <br />Organic Vapor Analyzer <br />or incidence: <br />I Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />6. <br />Potential Health and Safety <br />Phys' al Concerns: (check all that: apply & describe) <br />Cat or Cold Stress: OF (high ambient temp.) <br />Wlfioise Source: <br />2. Personal Protective Equipment <br />Rd" <br />( I qxygen Deficiency- <br />(q'-Excavarion: (falls, trips slipping, cave-ins) <br />Lev" Protection: C JA ( JB [ IC <br />[G,,51ard hat W <br />Handling and Transfer of a Hazardous Substance: <br />(Safety glasses/goggles <br />[eel toed/shank shoes or boors <br />(fire, explosions, etc.) <br />Confined Space entry. (explosions) <br />[ j Flame retardant coveralls <br />[Meavy equipment (physical injury & trauma resulting <br />trge'aring protection <br />from moving equipment) <br />Tyvek <br />Respirator, circle: APR or SCBA <br />Other, specify <br />A/P cartridge: <br />Safety vest <br />7. <br />Anticipated Biological Hazards: <br />Two-way communication <br />Snakes C j Insects C I Rodents Poisonous Plants <br />Other/Unknown (specify): <br />PART IV <br />PLAN APPROVAL <br />8. <br />Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Prepared by: Date: <br />Plan Approved by: Dare: <br />EH23081 (2/7/92) <br />