SITE-SPECIFIC SAFETY PLAN TEMPLATE
SITE-SPECIFIC SAFETY PLAN TEMPLATEDate: March 2014This Site-Specific Safety Plan Template contains general information that istypically part of a complete Site-Specific Safety Plan that may be required underapplicable Federal and State regulations when conducting soil excavation at theDel Oeste Veterinary Clinic property or along the adjacent Prairie Road. Allinformation contained in this Template should be verified for correctness beforeinclusion into a complete Site-Specific Safety Plan.Table 1. ContactsProject ManagerProject NumberSite/Project NameDel Oeste Veterinary ClinicSite Address/Location90238 Prairie Road, Eugene, OregonSite ContactNameRichard MosierPhone541-689-0205Emergency ContactsContactLocal PoliceNameEugene Police DepartmentLocal AmbulancePhone Number911911Local Fire DepartmentEugene Fire Department911Local HospitalPeace Health Sacred HeartMedical Center(541) 686-7300Local Hospital AddressRiverBend Campus3333 RiverBend DriveSpringfield, OR 97477Poison Control CenterOregon Poison CenterLocal Contractor’s Office1-800-222-1222
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Page 3Table 2. Locations of Nearest . . . (locate on map)TelephoneCell phoneRunning Water SourceDel Oeste officePublic RoadPrairie RoadRest RoomTable 3. Site Activities PlannedActivityLocationTable 4. Site StatusActiveInactiveAbandonedUnknownXDate
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Page 5Table 5. Hazard AssessmentHazard of ConcernHeat StressCold StressExplosive/FlammableOxygen DeficientExcessive NoiseInorganic ChemicalsOrganic ChemicalsPetroleum productsOtherChemical StateLiquidSolidGasOtherUnknownChemical nertOtherDescribe Potential Site Hazards.Soils and groundwater containing aged gasoline and diesel fuels may beencountered when excavating soil at the property and along Prairie Roadadjacent to the property.
Page 6Table 6. Safety ConsiderationsMonitoring EquipmentOrganic Vapor MeterO2 MeterExplosimeterH2S MeterOtherActions to Take if Hazards Listed in Table 5 (Hazard Assessment) OccurA project specific safety plan should be prepared to address specific risks associatedwith work that includes soil excavating at the property and along Prairie Road adjacentto the property.Table 7. Activity ConsiderationsWill Site Representative be Present?YesNoExact location of ChemicalsKnownXAssumedXUnknownXCharacterize Nearest Offsite PopulationResidentialXIndustrialXRuralUrban
Page 7Table 8. Personal Protective Equipment (PPE) to be UsedFootPetroleum resistant, as neededHandPetroleum resistant, as neededEye/FaceHeadEarClothingLong sleeve shirt and pantsRespiratoryAdditional GearOtherProject specific PPE should be addressed in a project specificsafety planFirst Aid KitYesNoTraining RequirementsType of CertificateYes HAZWOPER 40-HourX HAZWOPER 8-Hour RefresherX First Aid/CPR/AEDAs required byemployerNo
Page 8Table 9. Work PartyNameResponsibilityLevel of ProtectionSite Entry ProceduresCriteria for Changing ProtectionWork Limitations (time of day, conditions, etc.)Disposal of Regulated Materials, Drill Spoils, Decon WaterSee Contaminated Media Management Plan for DEQ UST Site #20-97-7034, Del OesteVeterinary Clinic, 90238 Prairie Road, Eugene, Oregon, dated March 2014
Page 9Table 10. Signatures for Site-Specific Safety PlanSignaturePrepared byReviewed byProject ManagerDate
SITE-SPECIFIC SAFETY PLAN TEMPLATE Date: March 2014 . This Site-Specific Safety Plan Template contains general information that is typically part of a complete Site-Specific Safety Plan that may be required under applicable Federal and State regulations when conducting soil excavation at the
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