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SITE H&= AND SAFETY PIAN (HASP) FORM <br /> Prepared Byv 120 ys 4 _ Date �� ���d W.0. GL 9 -C7/- <br /> 1. General Information <br /> A. Project 'Identification <br /> 1. Division 6At .2. Department/Office fy(O q D f <br /> 4. Site Nc-une 4'n v 5. Client 4 tic e f 5 f -- <br /> 6. work Location Address 9 29 F Nw Y G L r c C ZI <br /> (Street Address) (City) (State) (Zip) <br /> B. Site History rr } L <br /> 1. gibe briefly Pr-u fou! _ t��K i l e,�C A 4 k <br /> C. Scwe of Work <br /> 1. Describe bri fly row nos t 1� SA I S�+ '^"P(e S �l� L, S �"n r �C-d i �P T e <br /> 4h p� <br /> Site Visit only, Site HASPInot neces list pqrsonnel here sign-off below: <br /> D. Hazard Assessment and Regulatory Status <br /> 1. Indicate Yes (Y)/No (N) to types of hazards anticipated. ( ) Physio-chemical; <br /> Toxic Chemical - Levels ( >TLV-TW , >TLV-STEL, (�O) >IDLH; (,4-)) Bio-Hazards; <br /> {�U) Radiation; ( ) Physical; ( ) Construction type; (,o ) Industrial type; <br /> (,+�) Nuclear Industry type <br /> 2. Site Regulatory Status: 9tBCWSARA (,v ) U.S. EPA, ( u) State, (N ) NPL Site; <br /> RCRA - (P ) U.S. EPA, ( ) State; OSHA - ( ) 1910, ( ) 1926, ( ) State; <br /> NRC - {N ) 10 CFR 20; Other Fed. Agency - DOE, USATHM, (/u ) Air Force; <br /> Based on the Hazard Assessment and Regulatory Status, determine the Standard HASP(s) <br /> applicable to this project. Indicate below which Standard Hasp will be used and <br />` append the appropriate pages of this Form along with the Standard Plan. <br /> 3. Standard Plan to be used: (,v) Stack.Test (A)) Air Emissions (AJ) Asbestos <br /> ( ) Industrial Hygiene (,t)) Life Systerzs ( ) Hazardous Mat. (A)) Construction <br /> (�U) NRC/DOE (N ) USATHAMA (,c) ) Air Force <br /> D. Review and LINMroval Dogxree Cation <br /> 1. Reviewed By: a. P.M. Date B'30— <br /> b. P.D. Date <br /> c. DSO Date <br /> d. SHSC Date <br /> 2. Droved BY: late <br /> ( ) a. Corporate Health and Safety Director (CHSD) <br /> { ) b. DSO/RSOI(gnaly with specific delegation by CHSD? <br /> Project Start Da ;End Date `�. This Site HASP must be <br /> R.eissu roved for any activities conducted after: Date 1p - 0 <br /> Amendment Date(s) 1. 2. 3. 4. 5. <br /> �- �Jf�l cmy � ". sem. ••� ..x-=-k—�� �jal� �-.�j. E C E I� '��- � <br /> SEP 0 6 1121 <br /> ENVIRONMENTAL HEALTH <br /> PERMiT,/SERVICE5 <br />