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A <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> I. <br /> Site Name: �.�^� l. Chemicals Hazards <br /> Address: 1 Mjcr+ �, • Carcinogens: <br /> Contact Person: q NS Phone No: <br /> El Corrosives: <br /> Sweeps Number: ®Dusts: <br /> Proposed Date of investigation/inspection: (0-111-08 ❑Explosives: <br /> RJ Flammables: <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 /> L% PART III <br /> 3. Specific 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 /> I <br /> , <br /> 4. Type of Operation: <br /> I 010-SW ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: El YES F-1NO ❑Other'specify. <br /> Documented Groundwater contamination: <br /> ❑YES ❑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 /> Level of Protection: ❑A ❑B ❑C ❑D <br /> 6. Potential Health and Safety <br /> In Hard Hat. <br /> Physical Concerns:(check all that apply&describe) In <br /> H r Cold Stress: °F(high ambient temp.) <br /> Physical Glasses/goggles. <br /> 10 Steel toed/shank shoes or boots. <br /> ❑Noise Sources: <br /> ❑Flame retardant coveralls. <br /> ❑Oxygen Deficiency: e Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): <br /> ❑Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, F1 APR ❑SCBA <br /> etc..): El Respirator: <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 APPROVAL <br /> 7. Anticipated Biological Hazards: /! <br /> ❑Snakes ❑Insects ❑Rodents ❑Poisonous Plants Plan Prepared by: L--01a-AM Date: �J <br /> ❑Other/Unknown(specify): <br /> Plan Approved by: Date: d <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 />