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0 0 <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: L_ r.15 c,ry kA,,5 �A f35 <br /> 1. Chemicals Hazards <br /> Address: 1F95v -P'4'*, Ave— <br /> ,Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> �Flammables: c��ucY-� s <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR hrvestigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. <br /> ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation ofBorings/Monitoring Wells. <br /> Ef .- .. / <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: operations unless appropriate rationale or restrictions are provided) <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: yG' 261-111 [1 Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ftNO ❑Other,specify. <br /> Documented Groundwater contamination: <br /> ❑YES `Q NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> 6. Potential Health and Safety Level of Protection: El C]B ❑C �D <br /> Physical Concerns:(check all that apply&describe) C3 Hard Hat. <br /> ,Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> Noise Sources: C3 �'� —a "Steel toed/shank shoes or boots. <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): El Hearing protection. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, ❑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 /> ❑Other,specify <br /> PART IV-PLAN APPRO AL <br /> 7. Anticipated Biological Hazards: <br /> El Snakes El Insects ❑Rodents El Poisonous Plants <br /> Plan Prepared b '� Date: <br /> ❑Other/Unknown(specify): / <br /> 11 <br /> Plan Approved by: U� Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, I 19ho <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />