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SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: 1. Chemicals Hazards <br /> Address: Il0 W, �,�.�✓ � <br /> _ 0 Carcinogens: <br /> Contact Person: Phone No: JQg'JISS <br /> ❑Corrosives: <br /> Sweeps Number: ®Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> ®Flammables: Q <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific mc <br /> PART III <br /> Site Information: <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 /> operations unless appropriate rationale or restrictions are provided) <br /> Other: <br /> ❑Combustible Gas/Oxygen Meter. <br /> 4. Type of Operation: 644V ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> ❑ <br /> Evidence of leaks/soil contamination: El YES ❑NO Other,specify. <br /> If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: E]YES [I 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 ❑C D <br /> Hard Hat. <br /> Physical Concerns:(check all that apply&describe) <br /> Safety Glasses/goggles. <br /> ❑Hear or Cold Stress: °F(high ambient temp.) <br /> Q�Steel toed shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑ <br /> F-1 Oxygen Deficiency: Flame retardant coveralls. <br /> 9 Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> ElRespirator: E]APR ❑SCBA <br /> etc..): <br /> ❑Confined space entry:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving P9 Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes ❑Insects - r "E0 <br /> ❑Rodents El Poisonous Plants plan Prepared by: , Date: <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: V v� Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(12/17/2002) <br />