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1P • <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATI�, � UATION OF POTENTIAL HAZARDS <br /> I. Site Name: '— i A— s _� / �" /er <br /> Address: <br /> ®Carcinogens: Used Oil <br /> Contact Person: Phone No: Q Corrosives: <br /> Sweeps Number: A ❑Dusts: <br /> Proposed Date of investigation/inspection: ' I losives: GINS Ow r G�r O1�� <br /> ❑Flammables: oil filte s olvents I <br /> 2. Description and brief narrative of inspection activity: 0 Inorganic Gases: ' <br /> ❑New UST installation. ❑UAR Investigation. <br /> Q Metals: <br /> Q Tank Closure in Place. ❑Tank/Pipe Repair. 0 Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> ©Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: <br /> operations unless appropriate rationale or restrictions are provided) <br /> Q Combustible Gas/Oxygen Meter. <br /> V.-I Q Detector Tubes(Specify). <br /> 4. Type of Operation: //�� ,/�n(� 0 Photo ionization Detector. <br /> 5. Release History: til U r r l'1 r 0 Organic Vapor Analyzer. <br /> Q Other,specify. <br /> Evidence of leaks/soil contamination: [IYES Q NO <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: ❑A ❑B OC ®D <br /> ® <br /> Physical Concerns:(check all that apply&describe) Hard Hat. <br /> ®Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> ® <br /> Noise Sources: Steel toed/shank shoes or boots. <br /> ❑ <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> Q Excavation: falls,trips,sli ®Hearing protection. <br /> ( Aping,cave-ins): <br /> Q Handling and Transfer of a Hazardous Substance:(fire,explosions, Q Tyvek. <br /> etc..): Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ®Safety vest. <br /> equipment): ❑Two-way communication. <br /> Q Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> Q Snakes ❑Insects ❑Rodents ❑Poisonous Plants /?"10 <br /> Plan Prepared by: Jeffrey Wong Date: 0�/ <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: ��� Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> 21f6l )I- <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />