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IN <br />1 <br />D <br />PART I <br />PART II <br />GENERAL SITE INFORMATION <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: <br />1. Chemicals Hazards <br />Address: . G G p <br />[ ] Carcinogens: <br />Contact Person:-:av,4 Phone No. 7 <br />q+Corrosives: <br />Sweeps Number: 15Zp — A, ® , oY <br />= <br />ts: <br />Proposed Date of investigation/inspection: <br />=Iosives: <br />Flammables: <br />2. 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 />[ J Oxidizers: <br />'k]-Tank/Pipe Removal [ ] Re -excavation <br />[ J PCBs: <br />[ Installation of Borings/Monitoring Wells <br />PART III <br />3. Specific Site Information: <br />REQUIRED PERSONAL PROTECTIVE <br />Tank No. a/( ®Z,t Tank Capacity: Zx <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. Type of Operation: <br />unless appropriate rationale or restrictions are <br />provided) <br />5. Release History: <br />- TTtombustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: "S [ ] NO <br />[ ] Detector Tubes (Specify) <br />Documented Groundwater contamination: J. YES [ ] NO <br />[ ] Photoionization Detector <br />Background and description of any pTevious investigation <br />[ ] Organic Vapor Analyzer <br />or incidence: :!5 ® :r, G • • I°° <br />[ ] Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ] Heat or Cold Stress: of (high ambient temp.) <br />[ ] Noise Source: <br />2. Personal Protective Equipment <br />[ ] Oxygen Deficiency. <br />Level of Protection: [ ]A [ ]B tI.0 ND <br />Excavation: (falls, trips ,slipping, cave-ins)I <br />Hard hat <br />[ ] Handling and Transfer of a Hazardous Substance: <br />afety glasses/goggles <br />i9teel <br />(fire, explosions, etc.) <br />toed/shank shoes or boots <br />] Confined Space entry: (explosions) <br />[ ] Flame retardant coveralls <br />eavy equipment (physical injury & trauma resulting <br />Hearing protection <br />from moving equipment) <br />Tyvek <br />NRespirator, <br />circle: r SCBA <br />[ ] Other, specify <br />A/P cartridge: G — <br />[] Safety vest <br />7. Anticipated Biological Hazards: <br />[ ] Two-way communication <br />[ ] Snakes [ ] Insects [ ] Rodents [ ] Poisonous Plants <br />[ J Other/Unknown (specify): <br />PART IV <br />PLAN APPROVAL <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Prepared by. E?. _- Date: <br />_4P5h <br />Plan Approved by: _ Date:��`� <br />EH23081 (2/7/92) <br />