NC DWM Underground Tank Section SITE HEALTH AND SAFETY PLAN A. General Information Site Name ID # Location Proposed Date of Investigation: Date of Briefing: Date of Debriefing: Nature of Visit (check one): On-site reconnaissance Off-site reconnaissance Sampling Sampling Objectives and Overview: Remediation Overview: Health Department Official Contacted: Date of Contact:
Site Investigation Team: All site personnel have read the Site Health and Safety Plan and are familiar with its provisions. Team One Personnel Task Signature Team Two Personnel Task Signature Team Three Personnel Task Signature Prepared By: Reviewed By: B. SITE/WASTE CHARACTERISTICS Liquid Solid Sludge Gas Vapor Waste Characteristics: Corrosive Ignitable Radioactive Volatile Toxic Reactive Comments: Page 2
If known, list the substance of concern and amounts: Substance of Concern Warning Properties Exposure Limits Underground Utilities Checklist Required: YES NO Utility Locator/Contact Phone Date of Location Power Telephone Gas Water Sewer Facility Description: Size: Buildings: Disposal Methods Being Investigated: Unusual Features on Site (dike integrity, power lines, terrain, etc.): History of the Site: Page 3
Indicate All Anticipated Hazards: Biological Hazards Pressure Hazards Chemical Exposures Workplace Violence Electrical Hazards Ergonomic Hazards (stooping, bending, crawling, repetitive) Fire and Explosion Vision Hazards (impact/splash) Environmental/Weather Conditions Confined Spaces Radiation Excavations, Unstable Terrain, and Test Pits Noise / Vibration Traffic Hazards Oxygen Deficiency Atmospheres Wildlife Hazards Slip, Trip, Falls, Impact, and Struck-by Other: What method(s) will be implemented to reduce or eliminate exposure to these hazards? Page 4
Indicate all necessary PPE: Hard Hat Safety Boots Knee Length Boots Safety Glasses Safety Goggles Tyvek Suit/Other Eye Wash/First Aid Kit Hand Sanitizer Gloves DWM Reflective Safety Vest Binoculars Hearing Protection Other: D. WORK PLAN INSTRUCTION Map or Sketch Attached? Perimeter Identified? Command Post Identified? Zones of Contamination Identified? Personal Protective Equipment/Level of Protection: Surveillance Equipment: HNU OVA Detector Tubes Other: Rea Systems PID Oxygen Meter Radiation Monitor Niton XRF Air Monitoring Results: Equipment (w/ calibration date) Results (units) Comments Page 5
Decontamination Procedures Level C Respirator wash, respirator removal, suit wash (if needed), suit removal, boot wash, boot removal and glove removal. Level D Boot wash and rinse and boot removal, suit removal, glove and goggle removal. Goggles will be worn while deconning field equipment. Modifications Dispose of trash properly, on-site if possible. EMERGENCY PRECAUTIONS Route of Exposure First Aid Eyes- irrigate immediately Skin- soap and water wash Inhalation- fresh air and artificial respiration Ingestion- get medical attention immediately STATE POISON CONTROL CENTER: 1-800-848-6946 Location of Nearest Phone: Phone Numbers: Police: Fire: Hospital (Address and Phone Number): Page 6
Page 7
Page 8