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 Del Oeste Veterinary Clinic property or along the adjacent Prairie Road. All information contained in this Template should be verified for correctness before inclusion into a complete Site-Specific Safety Plan.

Table 1. Contacts	
Project Manager		
Project Number		
Site/Project Name	Del Oeste Veterinary Clinic	
Site Address/Location	90238 Prairie Road, Eugene, Oregon	
Site Contact	
Name	Richard Mosier	
Phone	541-689-0205	
Emergency Contacts	
Contact	Name	Phone Number	
Local Police	Eugene Police Department	911	
Local Ambulance		911	
Local Fire Department	Eugene Fire Department	911	
Local Hospital	Peace Health Sacred Heart Medical Center	(541) 686-7300	
Local Hospital Address	RiverBend Campus 3333 RiverBend Drive
Springfield, OR 97477	
Poison Control Center	Oregon Poison Center	1-800-222-1222	
Local Contractor’s Office			

Table 2. Locations of Nearest . . . (locate on map)	
Telephone	Cell phone	
Running Water Source	Del Oeste office	
Public Road	Prairie Road	
Rest Room		

		

Table 3. Site Activities Planned	
Activity	Location	Date	

			

			

Table 4. Site Status	
Active	X	
Inactive		
Abandoned		
Unknown		

Table 5. Hazard Assessment	
Hazard of Concern	
Heat Stress		
Cold Stress		
Explosive/Flammable		
Oxygen Deficient		
Excessive Noise		
Inorganic Chemicals		
Organic Chemicals	Petroleum products	
Other		
Chemical State	
Liquid		
Solid		
Gas		
Other		
Unknown		
Chemical Characteristics	
Corrosive		
Flammable	X	
Toxic	X	
Volatile	X	
Inert		
Other		

Describe Potential Site Hazards.

Soils and groundwater containing aged gasoline and diesel fuels may be encountered when excavating soil at the property and along Prairie Road adjacent to the property.

Table 6. Safety Considerations	
Monitoring Equipment	
Organic Vapor Meter		
O2 Meter		
Explosimeter		
H2S Meter		
Other		
Actions to Take if Hazards Listed in Table 5 (Hazard Assessment) Occur	
A project specific safety plan should be prepared to address specific risks associated with work that includes soil excavating at the property and along Prairie Road adjacent to the property.	

Table 7. Activity Considerations	
Will Site Representative be Present?	
Yes		
No		
Exact location of Chemicals	
Known	X	
Assumed	X	
Unknown	X	
Characterize Nearest Offsite Population	
Residential	X	
Industrial	X	
Rural		
Urban		

Table 8. Personal Protective Equipment (PPE) to be Used	
Foot	Petroleum resistant, as needed	
Hand	Petroleum resistant, as needed	
Eye/Face		
Head		
Ear		
Clothing	Long sleeve shirt and pants	
Respiratory		
Additional Gear		
Other	Project specific PPE should be addressed in a project specific safety plan	
		
First Aid Kit	
Yes		
No		
		
Training Requirements	
Type of Certificate	Yes	No	
HAZWOPER 40-Hour	X		
HAZWOPER 8-Hour Refresher	X		
First Aid/CPR/AED	As required by employer		

Table 9. Work Party	
Name	Responsibility	Level of Protection	

			

Site Entry Procedures	
	
Criteria for Changing Protection	
	
Work Limitations (time of day, conditions, etc.)	
	
Disposal of Regulated Materials, Drill Spoils, Decon Water	
See Contaminated Media Management Plan for DEQ UST Site #20-97-7034, Del Oeste Veterinary Clinic, 90238 Prairie Road, Eugene, Oregon, dated March 2014	

Table 10. Signatures for Site-Specific Safety Plan	
	Signature	Date	
Prepared by			
Reviewed by			
Project Manager