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N (r <br /> l <br /> SITE HEALTH AND SAFETY PLAN <br /> Complete all the following information. If a different Site Safety Plan is submitted, that Plan must include the <br /> following information: <br /> I. GENERAL SITE INFORMATION <br /> Site Name: <br /> Site Address: <br /> Contact Person: Phone: ?$ - S <br /> Site Identification umber: Proposed Date(s) of site work: <br /> II. DESCRIPTION OF INSPECTION ACTIVITY <br /> Purpose of Activity: Type of Site: <br /> ❑ Monitoring well installation ❑ Industrial <br /> ❑ Gas extraction well installation ❑ Gas station <br /> ❑ Domestic well installation ❑ Landfill <br /> ❑ Agricultural well installation ❑ Other(specify): <br /> tPf'-- Other(specify): d('ncP pksk l 1� <br /> Provide a brief description of the proposed activities: <br /> Investigation-derived material disposal: <br /> Soil: D 17)0 Gwdl ft eo_wu <br /> Water. <br /> Other: <br /> III. POTENTIAL HEALTH AND SAFETY HAZARDS <br /> Anticipated physical hazards. Check all that apply. <br /> ❑ heat (high ambient temperature) Heavy equipment <br /> cold Kphysical injury/trauma resulting from moving machinery <br /> Cts noise <br /> 0 oxygen depletion C<General construction <br /> ❑ asphyxiation ,physical injury and trauma <br /> ❑ electrical hazards <br /> ❑ Excavation <br /> 0 cave-ins ❑ Other(specify): <br /> (5--falls, trips, slipping <br />