Work Plan for Additional Assessment for BP 20066-16-60_Rev1

TABLE OF CONTENTS
1.0 INTRODUCTION................................................................................................................1 2.0 SITE BACKGROUND INFORMATION .........................................................................1
2.1 SITE LOCATION ....................................................................................................... 1
2.2 PREVIOUS REPORTING .......................................................................................... 2
3.0 SCOPE OF SERVICES .................................................................................................... 3
3.1 SOIL SAMPLING AND ANALYSIS ........................................................................ 3
3.1.1 POTENTIAL SOURCE AREA SOIL SAMPLING ........................................ 4
3.1.2 CUT DEPTH SOIL SAMPLING .................................................................... 4
3.1.3 DRIP LINE LEAD SOIL SAMPLING ........................................................... 5
3.2 SOIL GAS SURVEY .................................................................................................. 6
3.3 RECEPTOR SURVEY ............................................................................................... 7
3.4 REMEDIAL INVESTIGATION REPORT ................................................................ 7 4.0 INVESTIGATION DERIVED WASTE ......................................................................... 8 5.0 HEALTH AND SAFETY ................................................................................................. 8

LIST OF FIGURES

1 Site Location Map
2 Aerial Map
3 Assessment Sampling Locations Map

LIST OF APPENDICES

A Health and Safety Plan
Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

1 
1.0 INTRODUCTION

ESP Associates, P.A. (ESP) has prepared this Remedial Investigation (RI) Work Plan (Work Plan)
on behalf of Parkwood Residences, LLC. This Work Plan has been prepared in accordance with a
request from the North Carolina Department of Environmental Quality (NCDEQ) in a letter titled
“Additional Assessment” dated November 7, 2016. This Work Plan describes planned
environmental assessment activities to be performed at the subject Site located in Charlotte,
Mecklenburg County, North Carolina (hereafter called the “Site”). The Site has been accepted into
the Brownfields Program and is proceeding toward a Brownfields Agreement.

The Work Plan has been prepared to meet the specific requirements of the NCDEQ Inactive
Hazardous Sites Program Guidelines for Assessment and Cleanup dated October 2015, while sampling
activities will be performed in accordance with ESP’s Standard Operating Procedures and
Quality Assurance Manual dated April 18, 2013. Field personnel under this Work Plan will be
qualified to identify contaminated material and will comply with OSHA-required health and
safety training.

2.0 SITE BACKGROUND INFORMATION

2.1 SITE LOCATION

The approximate 3.41-acre subject Site is bounded by North Brevard Street, East 21st Street, North
Caldwell Street, and Parkwood Avenue in Charlotte, Mecklenburg County, North Carolina
(hereafter called the “Site”). A large portion of the Site, comprised of Tax Parcel Nos. 08107803,
08304101, 08304103, and 08304106, is developed with various commercial-type structures and a
residence while other portions are covered in grass with some trees (see Figures 1 and 2).

The commercial/industrial and residential property has associated street addresses of 1702, 1706
and 1720 N. Brevard Street; 1721 N. Caldwell Street; 414 and 418 E. 21st Street; and 427 E.
20th Street. Since 1995, the Site’s structures have been and are currently occupied by Industrial
Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

2 
Sign & Graphics, a manufacturer of industrial and commercial signs while an on-site single-
family residence is currently occupied.

The Site has historically consisted of commercial and industrial buildings along with a number of
single-and multi-family residences along E. 21st Street since at least 1938. Around 2005, E. 20th
Street reverted from the City of Charlotte to the abutting property owner and was subsequently
converted into a site entrance. Some of the historical site commercial/industrial occupants have
included Wiper & Waste manufacturing, a non-dry cleaning laundry, machine shops, automobile
repair, Charlotte Workshop for the Blind, Carolina Tool & Die, scrap metal storage, storage,
Keeter Dixon Pearre (a rags/textile scrap operation), and the Lions Club.

2.2 PREVIOUS REPORTING

As previously provided to NCDEQ, a Report of Phase I Environmental Site Assessment, dated
September 22, 2015 and a Report of Phase II Environmental Assessment, dated August 25, 2016,
have been prepared by ESP for the Site. The Phase II assessment activities which included soil
borings, hand auger borings, test pits, temporary and permanent monitoring wells along with the
laboratory analysis of soil and groundwater samples, identified the presence of tetrachloroethene
(PCE) within groundwater samples from several monitoring wells above 15A North Carolina
Administrative Code (NCAC) 2L.0202 groundwater standards (2L standards). Organics were
not detected within any of the analyzed soil samples above North Carolina screening levels.
Groundwater PCE Isoconcentration contours demonstrate that a portion of a dissolved PCE
groundwater plume extends onto the western portion of the site. The PCE plume appears to
originate from a hydraulically upgradient off-site source to the northwest, as the highest
dissolved concentrations are located along the historically undeveloped hydraulically upgradient
northwestern boundary of the site while decreasing in concentration to the southeast toward the
downgradient portion of the plume.

Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

3 
3.0 SCOPE OF SERVICES

The following activities are proposed to address the NCDEQ’s request for additional assessment as
detailed in their November 7, 2016 letter. Prior to initiation of the field activities, NC811 will be
called to locate and mark public utilities on the Site. Drilling services will be provided by a
driller licensed in the State of North Carolina while sample analytical services will be provided
by a North Carolina-certified laboratory under Title 15A of the NCAC 2H 0.0800 under Level 2
QA/QC data package protocol.

Retrieved soil will be logged and visually classified to identify soil types in general accordance
with the Unified Soil Classification System (USCS). Electronic soil boring records will be
prepared for each boring noting USCS classifications and other pertinent data. All soil borings
and soil gas probe locations completed as part of this Work Plan will be surveyed by a North
Carolina-licensed land surveyor.

All down-hole drilling equipment will be cleaned with a high pressure, hot water wash unit prior to
being brought to the Site. Subsequent to delivery to the Site, all down-hole drilling equipment will
be cleaned with a high pressure wash unit between soil boring locations. Hand augers will be
washed and scrubbed with a non-phosphate detergent, rinsed with clean water, and then rinsed with
deionized water.

3.1 SOIL SAMPLING AND ANALYSIS

Five soil borings (SB-1 through SB-5) will be advanced at the Site to further assess shallow and
deeper soil quality at locations depicted on attached Figure 3. The intent of the soil assessment is
to collect representative surficial soil within the area of the Site’s former machine shop and
former scrap metal storage building while also further characterizing deeper soil from areas of
the site to be cut during site re-development.

Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

4 
3.1.1 Potential Source Area Soil Sampling

Soil borings SB-1 and SB-2 will be advanced with a stainless-steel hand auger to depths of
approximately 2 feet below ground surface (ft bgs). Soil boring SB-1 will be completed through
a concrete slab associated with the former machine shop on the northern portion of the Site while
soil boring SB-2 will be completed in the area of former scrap metal storage building on the
central portion of the Site (see attached Figure 3).

Retrieved soil will be placed in resealable plastic bags and field screened for volatile organic
compounds (VOCs) with a photoionization detector (PID). A surficial soil sample (0-2 ft bgs)
will be collected from each boring and submitted to a North Carolina-certified laboratory to be
analyzed VOCs by EPA 8260, semi-volatile organic compounds (SVOCs) by EPA 8270, and the
eight RCRA metals (arsenic, barium, cadmium, chromium, lead, mercury, selenium and silver)
by EPA 6010/7471.

The following field quality control (QC) samples will also be collected:
• One VOC trip blank in each shipped cooler containing VOC samples.
• One duplicate soil sample to be analyzed for the full suite of parameters listed above.

3.1.2 Cut Depth Soil Sampling

Soil borings SB-3, SB-4 and SB-5 will be advanced along the western portion of the Site at
locations within the proposed cut area which are anticipated to involve the greatest cut depths (see
attached Figure 3). The boring locations have been adjusted to be located outside of existing Site
structures. Based on anticipated cut depths, soil boring SB-3 will be advanced to a total depth of 6
ft bgs, SB-4 to a total depth of 12 ft bgs, and SB-5 to a total depth of 8 ft bgs.

The soil borings will be advanced using a Geoprobe drill rig equipped with a Macro-core®
sampling probe (with acetate liners) to collect continuous soil cores from each borehole. Soil
samples will be collected for laboratory analysis from each soil boring as follow:
Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

5 
 A soil sample will be collected from the 0-2 ft bgs interval, placed in a resealable plastic
bag and field screened with a PID. The soil sample will then be placed in laboratory
provided containers to be analyzed for VOCs by EPA 8260, SVOCs by EPA 8270, and
the eight RCRA metals by EPA 6010/7471.
 Soil samples will be collected from each boring at 2-ft intervals from a depth of 2 ft bgs
to the boring’s termination depth. The 2-ft interval soil samples will be placed in
individual resealable plastic bags and field screened with a PID for VOCs. The
individual 2-ft interval bagged soil sample recording the highest PID reading will then be
placed in laboratory provided containers to be analyzed for VOCs by EPA 8260.
Remaining soil from the individual bagged samples collected from 2 ft bgs to the
boring’s termination depth will be composited into a single sample and transferred into
laboratory provided containers to be analyzed for SVOCs by EPA 8270, and the eight
RCRA metals by EPA 6010/7471.

The following field QC samples will also be collected:
• One VOC trip blank in each shipped cooler containing VOC samples.
• One duplicate composited soil sample to be analyzed for the full suite of parameters listed
above.

Upon completion of the soil borings, the resulting boreholes will be abandoned by the well
driller using either bentonite pellets or a cement/bentonite grout.

3.1.3 Drip Line Lead Soil Sampling

Four shallow soil borings will be advanced with a stainless-steel hand auger to a depth of
approximately 2 ft bgs from the drip line of the Site’s existing residential structure along its four
sides to assess for potential surficial soil impact from lead based paint. Soil from the 0-2 ft bgs
interval of all four borings will be composited into a single sample and transferred into
laboratory-provided containers to be analyzed for total lead by EPA 6010/7471. In addition, a
composited soil sample will also be collected and submitted to the laboratory for possible
analysis of TCLP lead pending results of the total lead analysis.
Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

6 
3.2 SOIL GAS SURVEY

Four temporary soil gas probes designated as GP-1 through GP-4 will be completed to assess for
subsurface soil gas in the southern and western portions of the Site at locations within the
footprint of planned structures as depicted on the attached Figure 3. Soil gas probes will be
installed within borings advanced using a Geoprobe drill rig equipped with a Macro-core
sampling probe. Retrieved soil samples will be field screened with a PID for VOCs.

Based on shallow groundwater in the area of the proposed gas probes and the need to place the
bottom of the probe’s screen no less than one foot above the water-table surface, it is anticipated
that the gas probes will be installed and screened as follows:
 GP-1 – screened from 5 to 6 ft bgs;
 GP-2 – screened from 5 to 6 ft bgs;
 GP-3 – screened from 6 to 7 ft bgs; and
 GP-4 – screened from 3 to 4 ft bgs.

The temporary gas probes will be constructed using flush joint threaded 2-inch diameter
polyvinyl chloride (PVC) riser with a 2-inch diameter 0.010-inch slot, 1-ft long PVC screen.
Filter sand sized for 0.010-inch slot screen will be placed in the annular space around the screen
to slightly above the top of the screen. The remaining annular space will be filled to the ground
surface with hydrated bentonite pellets. The PVC risers will be fitted with locking expansion
plugs. The gas probes will be abandoned upon completion of the field screening and sampling
effort.

Soil gas screening and sampling will be conducted no sooner than 24 hours after installation of
the last soil gas probe is complete. Soil gas screening will be conducted using a PID with
measurements recorded on a soil gas screening form. A duplicate PID reading will be recorded in
locations where there is a greater than 2% change in the reading. Additionally, soil gas samples
will be collected from each gas probe using laboratory-provided 6-Liter Summa canisters which
will be helium leak checked. The samples will be collected based on a flow rate of
Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

7 
approximately 200 cc/minute for a 30-minute sample time. The Summa canisters will be
delivered to a North Carolina-certified laboratory to be analyzed for VOCs by EPA TO-15.
The following field QC sample will also be collected:
 One duplicate soil gas sample will be collected to be analyzed for VOCs by EPA TO-15.

Weather conditions (ambient temperature, humidity, and barometric pressure readings) will be
recorded at least every hour during the sampling using the NOAA Charlotte weather station.
Sampling will not be performed on rainy days or exceedingly windy days.

3.3 RECEPTOR SURVEY

A receptor survey will be performed in accordance with NCDEQ’s Brownfields Property Receptor
Survey form to include an inventory listing and map of identifiable water supply wells, springs, and
surface water intakes used as sources of potable water within a 1,500-foot radius of the Site along
with existing Site conditions including a listing of building types and utilities. In addition, the Site
and adjacent properties will be evaluated for the existence of environmentally sensitive areas. The
receptor survey will be performed by conducting a Site reconnaissance by both foot and vehicle
while also contacting local utility providers and governing agencies.

3.4 REMEDIAL INVESTIGATION REPORT

Upon completion of the Work Plan activities, ESP will prepare a RI report summarizing field
activities and analytical results for the soil borings and soil gas sampling. The report will include
a summary of performed field activities, tabulated data in comparison to applicable screening
levels, maps, photographs, laboratory data reports, and associated field forms. In addition, the
report will include a detailed description of current Site operations since the Brownfields
Property Application was submitted. A completed Brownfields Property Receptor Survey form
will be attached to the report.

Remedial Investigation Work Plan ESP Project No. E6-DT19.601
Parkwood Station Site - Brownfields Project No. 20066-16-60 November 22, 2016

8 
4.0 INVESTIGATION DERIVED WASTE

Both solid and liquid-phase investigation derived wastes (IDW) will be generated by the field
investigation team. Materials that may become IDW and require proper containment and storage
include:
• Personnel protective equipment (PPE), plastic sheeting, disposable sampling equipment,
etc.
• Soil cuttings from drilling.
• Decontamination fluids such as wash water.

Wash water will be released to the ground surface on the Site. Soil cuttings will be used to fill in
the soil borings from which they were removed or will be spread on the surface within the area.
Used PPE, plastic sheeting, disposable sampling equipment (e.g., acetate liners), and other
sampling materials will be disposed offsite at an appropriate location (e.g., a municipal landfill).

5.0 HEALTH AND SAFETY

ESP has prepared a Health and Safety Plan (HASP) for the protection of on-site workers, the
surrounding community, and the environment from Site investigative activities (see Appendix A).
The health and safety of nearby residential and business communities will not be adversely
affected by planned activities under this Work Plan.

FIGURES
&<
&<&<
&<
&<
&<
&<
&<
&<
&<
&<
&<
&>
&>
&>
""
""
""
""""
&>
&>
&>
&>
&>&>
&>
&>
&>
&>
&>
&>
&>&>
&>
&>
&>
&>
&>
&>
&>
&>
&>
&>
&>
&>
&>
&>
&>
&>&>
&>
&>
&>
&>
&>
&>&>
&>
&>
&>
B-28
B-26AB-27
TP-1
TP-2
TP-3
TP-4
TP-5
HA-4
HA-23
HA-3
HA-2
HA-1
B-26
B-12
B-19
B-17 B-13
B-15
B-24
B-14
B-16
B-6
B-7
B-5B-3
B-8
B-4
B-11
B-10
B-9TMW-20
TMW-22
MW-1
MW-3
MW-5 MW-8
MW-2
MW-10D
MW-6
MW-11
MW-9
MW-7
MW-10S
MW-4
TMW-25
SB-3
SB-4
SB-5
SB-1
SB-2
##
##
##
##GP-1
GP-2
GP-3
GP-4
&<
&<&<
&<
&<
&<
&<
&<
&<
&<
&<
&<
&<
&<
&<
6 7 8694
682
7 0 2
6 8 6690
6
9
8
694
Parkwood Av
E 21st St
N C a l d w e l l S t
N B r e v a r d S t
0 30 60Feet
ESP Associates, P.A.
P.O. Box 7030Charlotte, NC 28241
phone [phone]
www.espassociates.com
SHEET TITLE
PROJECT
PROJECT NO.
SCALE
DRAWN BY
CHECKED BY
DT19.600
WB
CWDATE11/22/2016
FIGURE 3ASSESSMENT SAMPLING LOCATIONS MAP
PARKWOOD STATION SITEµ
Note: Locations are approximate.
As Shown
CHARLOTTE, NORTH CAROLINA
Legend
&>Proposed Boring
&>Boring - Soil Not Sampled
&<Monitoring Well - Soil Sampled
""Test Pit - Soil Not Sampled
Existing Buildings&>Boring - Soil Sampled
&<Monitoring Well - Soil Not Sampled
##Proposed Gas Probe
Planned Buildings
APPENDIX A

SITE-SPECIFIC HEALTH AND SAFETY PLAN
FOR
PARKWOOD STATION SITE
BROWNFIELDS PROJECT NO. 20066-16-60
CHARLOTTE, NORTH CAROLINA
ESP PROJECT NO. DT19-601

Date:
November 14, 2016

By:
ESP Associates, P.A.
P.O. Box 7030
Charlotte, North Carolina 28241
[phone]

CONTENTS
1 INTRODUCTION 1-1
2 SCOPE OF WORK 2-1
3 ORGANIZATIONAL STRUCTURE 3-1
4 HAZARD EVALUATION 4-1
5 TRAINING REQUIREMENTS 5-1
6 PERSONAL PROTECTIVE EQUIPMENT 6-1
7 MEDICAL SURVEILLANCE REQUIREMENTS 7-1
8 EXPOSURE MONITORING 8-1
9 DECONTAMINATION 8-1
10 EMERGENCY RESPONSE CONTINGENCY PROCEDURES 9-1

APPENDIX A HEALTH AND SAFETY FORM ACKNOWLEDGEMENT FORM
APPENDIX B SITE SPECIFIC TRAINING ACKNOWLEDGEMENT FORM
APPENDIX C MEDICAL DATA FORM
APPENDIX D EMERGENCY CONTACT INFORMATION
APPENDIX E INCIDENT REPORT

1-1
1 INTRODUCTION
The purpose of this Site-Specific Health and Safety Plan (HASP) is to:
 Identify the health and safety hazards of each phase of site operations, and
 Identify the procedures to be implemented to ensure employee protection.
The information in this HASP has been developed in accordance with applicable standards and
generally recognized industry practices. This document is, to the extent possible, based on site
characterization information provided to ESP Associates, Inc. (ESP).
This written program shall be made available to any contractor or subcontractor or their
representatives who will be involved with site operations; to employees; to employee designated
representatives; to OSHA personnel, and to personnel of other Federal, state, or local agencies with
regulatory authority over the site.
Inspections shall be conducted by ESP to determine the effectiveness of this HASP. Any
deficiencies in the effectiveness of the HASP shall be corrected by ESP.
In the event of conflicting safety procedures or requirements, ESP personnel shall implement
those safety practices which afford the highest level of protection.
Additional records and procedures to support the requirements of this HASP are available upon
request from the Site Superintendent.

2-1
2 SCOPE OF WORK
ESP will perform the following activities at this site:
 Site Mobilization
 Completion of Soil Borings
 Completion of Monitoring Wells
 Completion of Soil Gas Probes
 Monitoring the Excavation of Soils/Waste
 Collection of Surface Water Samples
 Collection of Groundwater Samples
 Collection of Sediment Samples
 Collection of Soil Samples
 Collection of Waste Samples
 Collection of Soil Gas Samples
 Site Demobilization
 Land Surveying and Geophysical Surveying

If the scope of work is altered or if additional tasks are assigned, an addendum to this HASP
shall be developed to address any additional potential specific hazards associated with these
changes.

3-1
3 ORGANIZATIONAL STRUCTURE ESP EMPLOYEES
The requirements of this HASP will be implemented through an effective organizational
structure that includes the Corporate Health and Safety Officer, Site Superintendent, employees,
equipment operators, and subcontractors.
Corporate Health and Safety Officer
The Corporate Health and Safety Officer (CHSO) shall be responsible for the overall
implementation of the HASP. This shall include, but is not limited to, review and approval of
the HASP, communication of this HASP to Subcontractor personnel, consultation with the
Client/Owner regarding appropriate changes to the HASP, and relating any changes through the
affected organizational structure.
Site Superintendent
A Site Superintendent (SS) shall be appointed by the CHSO prior to the commencement of field
activities. The SS is the person who, under the supervision of the CHSO, is responsible for
implementing site health and safety requirements. Specific duties of the SS include:
 Perform and document a safety orientation for all ESP site personnel which will serve to
familiarize all personnel with the procedures, requirements, and provisions of this
HASP.
 Providing for the safety of any visitors who enter the work area.
 Orders the immediate shutdown of site activities in the case of a medical emergency,
unsafe condition, or unsafe practice.
 Provide the safety equipment, personal protective equipment, and other items necessary
for ESP employees.
 Enforce the use of required safety equipment, personal protective equipment, and other
items necessary for employee or community safety.
 Conduct job site inspections as a part of quality assurance for safety and health.
 Report safety and health concerns to management as necessary.

3-2

Employees
All employees are responsible for their own safety as well as the safety of those around them.
All employees shall use any equipment provided in a safe and responsible manner, as directed by
their supervisor.
All employees have the obligation and right to report unsafe work conditions, previously
unrecognized safety hazards, or safety violations of others. If you wish to make such a report, it
may be made orally to your supervisor or other member of management, or you may submit your
concern in writing, either signed or anonymously.
Employees are expected to take the following actions as appropriate:
 Suspend any operations which may cause an imminent health hazard to employees,
subcontractors, or others.
 Correct job site hazards when possible to do so, without endangering life or health.
 Be vigilant for any ill effects experienced by any crew member, especially those
symptoms caused by heat stress or chemical exposure.
 Report safety and health concerns to the SS.
Equipment Operators
All equipment operators are responsible for the safe operation of heavy equipment under their
control. Operators are responsible for inspecting their equipment to ensure safe performance.
Brakes, hydraulic lines, backup alarms, and fire extinguishers must be inspected during site
mobilization. Equipment will be taken out of service if an unsafe condition occurs. All
equipment operators are required to wear seat belts during operation.
3.1 Subcontractors
All ESP subcontractors shall be expected to execute their specific job duties in a safe manner,
and to provide sufficient resources, personnel and equipment to meet this expectation. To
facilitate subcontractor preparation for this work effort, a copy of this HASP will be provided to
each subcontractor. ESP subcontractors are expected to take this information, combine it with
their own experiences, procedures, and expertise, to produce an effective health and safety plan
suitable for their work at this site. All HASPs produced by ESP subcontractors shall be made
available to ESP upon request.

4-1

4 HAZARD EVALUATION
This section identifies and evaluates the potential chemical, physical, and biological hazards
which may be encountered during the work activities identified in Chapter 2.
4.1 Chemical Hazards
The chemical hazards of concern within groundwater, soil, air, and waste at the site could
potentially include volatile organic compounds (VOCs), semi-volatile organic compounds
(SVOCs), metals, asbestos, pesticides, herbicides, and PBCs. The routes of exposure from these
contaminants are primarily through inhalation of organic vapors and dusts, and by direct contact
with contaminated media.
There are also sample bottles that hold preventives including methanol, hydrochloric acid, nitrate
acid, and sulfuric acid. Proper care will be taken so these bottles will not be broken. If there is
an accident, first aid procedures will need to be followed to prevent physical harm. Primary
concerns are inhalation and burns due to skin contact.
4.2 Physical Hazards
Physical hazards that may be present during project work include potential for close proximity to
heavy equipment, working in trenches and excavations, noise, overhead and underground
utilities, slip/trip/hit/fall injuries, heat stress/cold stress, insects, snakes, spiders, drilling hazards,
and other potential adverse weather conditions.
Utility Clearances
 Elevated superstructures (e.g., drill rigs, cranes) shall remain a distance of 10 feet away
from utility lines (50 Kv or less), and 20 feet away from power lines (>50 Kv).
 Prior to all intrusive activities (e.g., excavating), locator line services will be contacted to
mark underground lines.
 Personnel involved in intrusive work shall determine the minimum distance from marked
utilities which work can be conducted with the assistance of the Local Agency.

4-2

4.2.1 Heavy Equipment
Working around heavy equipment can be dangerous because of the size and power of the
equipment, the limited operatory field of vision and the noise levels that can be produced by the
equipment. Heavy equipment to be utilized at the site shall include a variety of drill rigs,
backhoes, dozers, track loaders, and off-road trucks.
The following practices shall be followed by operators when using heavy equipment:
 Equipment should be inspected daily by the operator to ensure that the equipment is in safe
operating condition.
 When not in use, hydraulic and pneumatic components should be left in down or "dead"
position.
 Roll-over protection shall be provided on uneven terrain sites.
 No riding on vehicles or equipment except in fixed seats.
 Seat belts should be worn at all times.
 Backup alarms, automatically activated and loud enough to be heard above background
noise, are required to be operational on all heavy equipment.
 Parking brakes should always be applied on parked equipment.
 Equipment should never be operated closer than 10 feet from utility lines.
 Windshields must be maintained clean and free of visual obstructions.
To ensure the safety of all personnel in the work area, the following safety procedures regarding
heavy equipment must be reviewed prior to and followed during work activities:
 Ensure that equipment operators are trained and/or experienced in the operation of the
specific equipment.
 Personnel should never approach a piece of heavy equipment without the operator’s
acknowledgment and stoppage of work or yielding to the employee.
 Never walk under the load of a bucket or stand beside an opening truck bed.
 Maintain visual contact with the operator when in close proximity to the heavy
equipment.
 Wear hearing protection while on or around heavy equipment, when normal conversation
cannot be heard above work operations.

4-3

 Steel-toed shoes, safety glasses, and a hard hat shall be worn for all work conducted near
heavy equipment.
4.2.2 Excavation and Trenching
The following safety guidelines shall be adhered to while conducting excavation and trenching
operations:
 Prior to opening an excavation, effort shall be made to determine whether underground
installation (i.e., sewer, telephone, water, fuel, electric lines, etc.), will be encountered
and the estimated location. When the excavation approaches the estimated location of
such installation, the exact location shall be determined and when it is uncovered,
proper supports shall be provided for the existing installation. Utility companies shall
be contacted and advised of proposed work prior to the start of actual excavation.
 Ladders will be used in any trench greater than 4 feet in depth, and must be available
with every 25 feet of lateral travel. The ladders must extend above the trench at least
3 feet or greater.
 Protective systems (i.e., shoring/bracing, sloping or benching) shall be used if personnel
are to enter an excavation with a depth greater than 5 feet.
 Sloping or benching shall be in accordance with the OSHA standard and shall correspond
to the proper ratio (i.e., 1½:1) as per soil type.
 Air monitoring for potential hazardous atmospheres (i.e., combustible gases, volatile
organics, and oxygen deficient environments) shall be conducted prior to personnel
entering the trench with a depth at 4 feet or greater.
 Barriers shall be erected around excavations in remote work locations. Backfill all
excavations, temporary wells, pits, and shafts when work is completed.
 Vehicular traffic and heavy equipment shall remain at least 4 feet from the face of the
excavation. All excavated or other materials shall be stored and retained at least 2 feet
from excavation.
 The excavation shall be inspected by the selected competent person throughout the work
day, during any change in conditions (i.e., rain, cracking/fissures), and at a minimum
twice daily.

4-4

4.2.3 Heavy Lifting
When lifting objects, use the following proper lifting techniques:
 Keep your feet shoulder width apart to get the best footing possible.
 Bend at the knees, not at the waist.
 Tighten stomach muscles to offset the force of the load.
 Grasp the object at opposite corners.
 Lift with the legs instead of the back muscles.
 Keep the back upright and avoid twisting.
 Most importantly, think before lifting.
4.2.4 Electrical Hazards
No employee shall be permitted to work on any part of an electrical power circuit unless the
person is protected against electric shock by de-energizing the circuit and grounding it, or has
been locked and tagged out:
 All electrical wiring and equipment shall be intrinsically safe for use in potentially
explosive environments and atmospheres.
 All electrical wiring and equipment shall be a type listed by Underwriters’ Laboratories
(UL) or Factory Mutual (FM) for the specific application.
 All installations shall comply with the National Electric Code (NEC) and the National
Electric Safety Code (NESC).
 All electrical circuits shall be grounded according to NEC and NESC Code. Ground
fault circuit interrupters shall be used in the absence of properly grounded circuitry or
when portable tools must be used around wet areas.
 All live wiring or equipment shall be guarded to protect all persons or objects from harm.

4-5

4.2.5 Adverse Weather Conditions
The SS shall decide on the continuation or discontinuation of work based on current and pending
weather conditions. Electrical storms, tornado warnings, and strong winds are examples of
conditions that would call for the discontinuation of work and evacuation of site.
 No work will be permitted during any type of electrical storm.
4.2.6 Slip/Trip/Hit/Fall
Slip/trip/hit/fall (S/T/H/F) injuries are the most frequent of all injuries to workers. They occur
for a wide variety of reasons, but can be minimized by the following prudent practices:
 Spot check the work area to identify hazards.
 Establish and utilize a pathway which is most free of slip and trip hazards.
 Beware of trip hazards such as wet floors, slippery floors, and uneven surfaces or terrain.
 Carry only loads which you can see over.
 Keep work areas clean and free of clutter, especially in storage rooms and walkways.
 Communicate hazards to on-site personnel.
 Secure all loose clothing, ties, and remove jewelry while around machinery.
 Report and/or remove hazards.
 Keep a safe buffer zone between workers using equipment and tools.
4.2.7 Heat Stress
Recognition and Symptoms
Temperature stress is one of the most common illnesses at hazardous waste sites.
Acclimatization and frequent rest periods must be established for conducting activities where
temperature stress may occur. Below are listed signs and symptoms of heat stress. Personnel
should follow appropriate guidelines if any personnel exhibit these symptoms:
Heat Rash - Redness of skin. Frequent rest and change of clothing.
Heat Cramps - Painful muscle spasms in hands, feet, and/or abdomen. Administer
lightly-salted water by mouth, unless there are medical restrictions.

4-6

Heat Exhaustion - Clammy, moist, pale skin, along with dizziness, nausea, rapid pulse,
fainting. Remove to cooler area and administer fluids.
Heat Stroke-— Hot dry skin; red, spotted or bluish; high body temperature of 104°F, mental
confusion, loss of consciousness, convulsions or coma. Immediately cool victim by
immersion in cool water. Wrap with wet sheet while fanning, sponge with cool liquid
while fanning; treat for shock. DO NOT DELAY TREATMENT. COOL BODY
WHILE AWAITING AMBULANCE.
Work Practices
The following procedures will be carried out to reduce heat stress:
 Acclimatization
 Work/rest regimes
 Liquids that replace electrolytes/salty foods available during rest
 Use of buddy system
Acclimatization
The level of heat stress at which excessive heat strain will result depends on the heat tolerance
capabilities of the worker. Each worker has an upper limit for heat stress beyond which the
resulting heat strain can cause the worker to become a heat casualty. In most workers,
appropriate repeated exposure to elevated heat stress causes a series of physiologic adaptations
called acclimatization, whereby the body becomes more efficient in coping with the heat stress.
Work/rest regimes will be partially determined by the degree of acclimatization provided.
4.2.8 Cold Stress
Recognition and Symptoms
Ambient air temperatures during site activities may create cold stress for on-site workers.
Procedures for recognizing and avoiding cold stress must be followed. Cold stress can range
from frostbite to hypothermia. Below are listed the signs and symptoms of cold stress.
Personnel should follow the appropriate guidelines if any personnel exhibit these symptoms:
Frostbite - Pain in the extremities and loss of manual dexterity. "Frostnip" or reddening of
the tissue, accompanied by a tingling or loss of sensation in the extremities. Continuous
shivering.
Hypothermia - Pain in the extremities and loss of manual dexterity. Severe, uncontrollable
shivering. Inability to maintain level of activity. Excessive fatigue, drowsiness, irritability,

4-7

or euphoria. Severe hypothermia: clouded consciousness, low blood pressure, pupil
dilation, cease of shivering, unconsciousness, and possible death.
Remove the patient to a warm, dry place. If clothing is wet, remove and replace with dry
clothing. Keep patient warm. Re-warming of patient should be gradual to avoid stroke
symptoms. Dehydration of the loss of body fluids may result in cold injury due to a
significant change in blood flow to the extremities. If patient is conscious and alert, warm
sweet liquids should be provided. Coffee and other caffeinated liquids should be avoided
because of diuretic and circulatory effects. Extremities affected by frostbite should be
gradually warmed up and returned to normal temperature. Moist compresses should be
applied; begin with lukewarm compresses and slowly increase the temperature as changes
in skin temperature are detected. Keep patient warm and calm, remove to a medical
facility as soon as possible.
Work Practices
The reduction of adverse heath effects from cold exposure is achieved by adopting the following
work practices:
 Providing adequate insulating dry clothing to maintain core temperature above 98.6F to
workers if work is performed in air temperature below 40F. Wind chill cooling rates
and the cooling power of air are critical factors. The higher the wind speed and the
lower the temperature in the work area, the greater the insulation value of the
protective clothing required.
 If the air temperature is of 32F or less, hands should be protected.
 If only light work is involved and if the clothing on the worker may become wet on the
job site, the outer layer of the clothing in use should be impermeable to water. With
more severe work under such conditions, the outer layer should be water repellent, and
the outer wear should be changed as it becomes wettened. The outer garments should
include provisions for easy ventilation in order to prevent wetting of inner layer by
sweat.
 If available clothing does not give adequate protection to prevent cold injury, work
should be modified or suspended until adequate clothing is made available, or until
weather conditions improve.
 Heated warming shelters should be available nearby (e.g., use of on-site trailer). The
workers should be encouraged to use these at regular intervals, the frequency
depending on the severity of the environmental exposure. When entering the heated
shelter, the outer layer of clothing should be removed and the remainder of the clothing
loosened to permit heat evaporation or a change of dry work clothing provided.

4-8

 Warm sweet drinks and soups shall provide the correct caloric intake and fluid volume.
The intake of caffeinated coffee should be limited because of the diuretic and
circulatory effect.
 The weight and bulk of clothing should be included in estimating the required work
performance and weights to be lifted by the worker.
As with heat stress:
 Implementing a buddy system in which workers are responsible for observing fellow
workers for early signs and symptoms of cold stress.
 Unacclimatized employees should not be required to work full-time in cold until they
become accustomed to the working conditions and required protective clothing.
4.3 Biological Hazards
4.3.1 Tick-Borne Diseases
Lyme disease is caused by a bacterial parasite called spirochete, and is spread by infected ticks
that live in and near wooded areas, tall grass, and brush. Once the tick deposits the spirochete, it
must feed on the host blood for 12 to 24 hours before it can transmit the disease. The ticks that
cause the disease in the Northeast and Midwest are often no bigger than a poppy seed or a
comma in a newsprint. The peak months for human infection are June through October. There
are many other tick borne diseases such as Rocky Mountain Spotted Fever which can be carried
by a variety of ticks. The prevention and treatment of these diseases are similar to those of Lyme
disease.
Prevention
Ticks hang on blades of grass or shrub waiting for a host to come by. When a host brushes
against the vegetation, the tick grabs on. Ticks usually first climb onto a person’s legs and then
crawl up looking for a place to attach. Preventative measures include wearing light-colored
clothing, keeping clothing buttoned, tucking pant legs in socks, and keeping shirt tails tucked in.
Periodic checks for ticks should be made during the day, and especially at night. Hair should
also be checked by parting it and combing through it to make sure that no ticks have attached to
the scalp. Also, check clothing when it is first removed, before ticks have a chance to crawl off.
The most common repellent recommended for ticks is N,N-dimethyl-m-toluamide, or DEET. It
is important to follow the manufacturer's instructions found on the container for use with all
insecticides especially those containing DEET.
In general, DEET insect repellent should only be applied to clothing, not directly on the skin.
Do not apply to sunburns, cuts or abrasions. Use soap and water to remove DEET once indoors.

4-9

Removal
The best way to remove a tick is removal by tweezers. If tweezers are not available, cover your
fingers (tissue paper) while grasping the tick. It is important to grasp the tick as close as possible
to the site of attachment and use a firm steady pull to remove it. When removing the tick, be
certain to remove all the mouth parts from your skin so as not to cause irritation or infection.
Wash hands immediately after with soap and water, and apply antiseptic to the area where tick
was removed.
Testing and Symptoms of Lyme Disease
A variety of tests exist for determining Lyme Disease infection. However, most of these tests
are not exact. The first symptoms of Lyme Disease usually appear from 2 days to a few weeks
after a person is bitten by an infected tick. Symptoms usually consist of a ring-like red rash on
the skin where the tick attached. The rash is often bull's eye-like with red on the outside and
clear in the center. The rash may be warm, itchy, tender, and/or "doughy". Unfortunately, this
rash appears in only 60 to 80 percent of infected persons. An infected person also has flu-like
symptoms of fever, fatigue, chills, headaches, a stiff neck, and muscle aches and pains
(especially knees). Rashes may be found some distance away from original rash. These
symptoms often disappear after a few weeks.
4.3.2 Poisonous Plants
Common Poison Ivy (Rhus radicans) grows as a small plant, a vine, and a shrub. Poison Ivy
occurs in every state. The leaves always consist of three glossy leaflets. Poison Sumac (Rhus
vernix) grows as a woody shrub or small tree 5 to 25 feet tall. It usually contains nine leaves,
with eight paired leaves and one on top, and is common in swampy areas. The plants are potent
sensitizes and can cause a mild to severe allergic reaction. This reaction is called contact
dermatitis.
Dermatitis, in Rhus-sensitive persons, can result from contact with the milky sap found in the
roots, stems, leaves, and fruit. The sap may retain its potency for months or years in a dry
atmosphere, and can occur during any time of the year. The sap may also be carried by animals,
equipment or apparel.
The best form of prevention is to avoid contact. This can occur by wearing long sleeves and
gloves if necessary. Disposal clothing, such as Tyvek, is recommended in high risk areas to
avoid exposure from contaminated apparel. Barrier creams and cleaners are also recommended.
4.3.3 Blood Poisoning
Blood poisoning is a term used to indicate a large number of bacteria present in the circulating
blood. The most common symptom of blood poisoning is the reddening of skin which advances

4-10

towards the heart. For example, if the point of contact is the hand than a red line will appear at
the hand and extended up the arm.
Personnel protective equipment shall be worn to prevent direct contact with media which may be
contaminated with bacteria or viral agents.
Signs and symptoms include swelling, stiffness and tenderness in the affected area, fatigue, chills
and fever, pustules, and abscesses. If allowed to progress, the organisms may multiply and cause
an overwhelming infection and death.

5-1

5 TRAINING REQUIREMENTS
5.1 Worker Competency and Experience
All personnel conducting work at this site shall have demonstrated competency in the skills and
activities relevant to their work at the site. This competency may be demonstrated through
continuing education, work experience, or a combination thereof. The relevant subject matter
may include, but is not limited to, heavy equipment operation, hand signals, first aid, hand tool
safety, electrical safety, personal protective equipment usage, material handling, and trenching
and excavation.
5.2 Site-Specific Training
An initial site-specific safety briefing shall be conducted by the Site Superintendent prior to
commencement of work and/or entering the site. During this initial training session, employees
shall be instructed on the following topics:
 Content and implementation of the HASP.
 Site hazards and controls.
 Intended use of personal protective equipment.
 Emergency information, including local emergency response team phone numbers, route
to nearest hospital, and emergency response procedures.
The site safety orientation shall be documented on the form contained in Appendix A.
During the project, at intervals not to exceed seven calendar days, supplemental safety meetings
shall be conducted by the Site Superintendent to discuss work performed to date, safety incidents
(if any), potential health and safety hazards associated with upcoming tasks, and necessary
precautions to be taken.
All site training shall be documented on the form contained in Appendix B.

6-1

6 PERSONAL PROTECTIVE EQUIPMENT
6.1 Protocol for Workers
All personnel involved with this work effort shall wear personal protective equipment (PPE)
equivalent to the Level D protocol described below. The Site Superintendent is qualified to modify
this protocol in accordance with the hazards of the specific activities being performed at the time.
Where there is increased potential for contact with liquids, the protocol shall be upgraded to the
Modified Level D protocol described below.
The use of respiratory protective equipment is not contemplated by this HASP. Work requiring the
use of respiratory protective equipment shall require modification of this HASP to reflect the
proper usage of these devices.
PPE Designation Mandatory Items Worn at Direction of SS

Level D

 Hard hat
 Work uniform
 Safety glasses
 Steel-toed boot

 Hearing protection
 Traffic Vest

Modified Level D

 Hard hat
 Work uniform
 Safety glasses
 Steel-toed boot
 Resistant coveralls
 Rubber gloves
 Rubber boots

 Hearing protection
 Traffic Vest

6.2 Protocol for Visitors
Visitors shall be required to wear personal protective equipment equivalent to the Level D
protocol described above. The Site Superintendent is responsible for making changes to the
Visitor PPE Protocol if revisions are deemed necessary.

7-1

7 MEDICAL SURVEILLANCE REQUIREMENTS
ESP administers an ongoing, effective medical surveillance program in accordance with 29 CFR
1910.120 (f). Employees who participate in this program include:
 Employees who are exposed to hazardous substances or health hazards at or above the
established permissible exposure limit for 30 days or more per year,
 Employees who wear a respirator for 30 days or more per year, and
 Any employees who are injured, become ill, or develop signs or symptoms due to possible
overexposure involving hazardous substances or health hazards.
The content of medical examinations made available to employees is determined by the
attending physician, and in general, follow the guidelines contained in the Occupational Safety
and Health Guidance Manual for Hazardous Waste Site Activities.
Additional information on the medical surveillance program is available from the Corporate
Health and Safety Officer.
Medical information relevant to the administration of first aid to on-site employees is contained
on the Medical Data Sheet, which is kept under the control of the Site Superintendent (see
Appendix C).
Site-specific additions to the medical surveillance program are not contemplated for this work
effort.

8-1

8 DECONTAMINATION
All site personnel shall follow the decontamination procedures outlined below.
8.1 Contamination Prevention
One of the most important aspects of decontamination is the prevention of the spread of
contamination. Good contamination prevention will minimize employee exposure, and ensure
good personal hygiene. Proper decontamination procedures and the following procedures of
contamination avoidance shall reduce the potential exposure and the spread of contamination
include:
 Do not walk through areas of obvious or known contamination.
 Do not handle or touch contaminated materials directly.
 Fasten all closures on suits, covering with tape if necessary.
 Take particular care to protect any skin injuries.
 Stay upwind of airborne contaminants, when possible.
8.2 Personal Decontamination
All PPE will be disposed of and/or decontaminated at the conclusion of each work day as
described below. Decontamination procedures will follow the concept of deconning the most
contaminated PPE first.
All disposable equipment shall be doffed before meal breaks and at the conclusion of the work
day and replaced with new equipment prior to commencing work. Non-disposable equipment
will be fully decontaminated and then placed in a clean storage area.
8.2.1 Level D and Modified Level D Decontamination
Level D decontamination procedures are as follows:
 Step 1 - Remove all visible contamination and loose debris.
 Step 2 - Remove all outer clothing that came in contact with the contamination (i.e., boot
covers and outer gloves) and either dispose of in disposable container or wash in
detergent solution and rinse.

8-2

 Step 3 - Remove protective clothing; dispose of in disposable container.
 Step 4 - Wash and rinse hands.
8.3 Equipment Decontamination
8.3.1 Heavy Equipment
All vehicles and heavy equipment used (e.g., trucks, drill rig, backhoe, bulldozer) that encounter
waste materials will be decontaminated prior to leaving the project site using procedures dictated
by the SS.
When possible, vehicles should be parked off site or in a non-contaminated area of the site to
minimize contamination and thus, avoid the need to decontaminate.

9-1
9 EMERGENCY RESPONSE CONTINGENCY PROCEDURES
9.1 On-Site Emergencies
The Site Superintendent is responsible for contacting local emergency services in the event of an
emergency situation.
Emergency contact information, including the hospital location, directions, and emergency
phone numbers is contained on the form in Appendix D.
9.1.1 Accident, Injury, and Illness Reporting and Investigation
Any work-related incident, accident, injury, illness, exposure, vehicle incident, or property loss
must be reported to the Site Superintendent and to the Safety Manager as quickly as possible.
All incidents shall be documented on the form contained in Appendix E and forwarded to the
CHSO.
The report must be filed for the following circumstances:
 Accident, injury, illness, or exposure of an employee.
 Injury of a subcontractor.
 Damage, loss or theft of property
 Any incident, regardless of fault, which involves company equipment, a company
vehicle, rental vehicle, or personal vehicle while the employee is acting in the course
of employment.
All incidents will be investigated by the CHSO, or designee. This investigation will focus on
determining the cause of the accident and modifying future work activities to eliminate the
hazard.

9-2
9.2 Emergency Equipment/First Aid
Basic first aid supplies (bandages, gauze, and tape) will be located in the first aid box. The first
aid box along with first aid manuals and Medical Data Sheets will be located in the Site Trailer
or Site Superintendent vehicle. Other on-site emergency equipment includes an emergency
alarm (i.e., air horn), emergency eyewash, fire extinguisher, potable water and drinking cups,
anti-bacterial soap, and walkie-talkies.
9.3 Site Evacuation
In the event of an emergency situation such as fire, explosion, significant release of toxic gases,
etc., an air horn or other appropriate device will be sounded for approximately 10 seconds
indicating the initiation of evacuation procedures. All personnel in both the restricted and
non-restricted area will evacuate and assemble near the Support Zone or other safe area as
identified by the Site Superintendent prior to the beginning of field operations. The location
shall be upwind of the area where the hazard originated, if possible.
For efficient and safe evacuation and assessment of the emergency situation, the Site
Superintendent will have authority to initiate proper action if outside services are required.
Under no circumstances will incoming personnel or visitors (other than designated responders)
be allowed to proceed into the work area once the emergency signal has been given.
The Site Superintendent shall ensure that access for emergency equipment is provided and that
all combustion apparatus has been shut down once the alarm has been sounded.

APPENDIX A
HEALTH AND SAFETY PLAN
ACKNOWLEDGMENT FORM
ESP ASSOCIATES, INC. – PARKWOOD STATION SITE
Site Safety Briefing
Each employee conducting field work shall sign this form after the pre-entry briefing is completed and prior to
commencing work on site. This form shall be kept at the site during the work effort. At the conclusion of the
project, the form shall be sent to the CHSO for inclusion into the project file.
Site Personnel Sign-off
By affixing your signature to the space below, you acknowledge that you have been briefed on the
work effort at this site, the potential safety and health hazards to be encountered, methods to prevent
exposure to these safety and health hazards, and the contents of the Site-Specific Health and Safety
Plan.
I understand this briefing and will comply with the safety requirements for this project.

Signature: _____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________

***Retain this form in the project files***

APPENDIX C
SITE-SPECIFIC TRAINING
ACKNOWLEDGMENT FORM
ESP ASSOCIATES, INC. – PARKWOOD STATION SITE

SAFETY MEETING TOPIC - _______________

Each employee conducting field work shall sign this form after each site-specific training activity is completed.
This form shall be kept at the site during the work effort. At the conclusion of the project, the form shall be sent to
the CHSO for inclusion into the project file.
Site Personnel Sign-off
By affixing your signature to the space below, you acknowledge that you have been briefed on the
safety topic identified at the top of this form.
I understand this briefing and will comply with the safety requirements for this project.

Signature: _____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________

APPENDIX C
Signature (Continued):
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________
_____________________________________________ Date: _______________

APPENDIX C
MEDICAL DATA SHEET

This brief Medical Data Sheet will be completed by all personnel potentially working on-site and will be kept in the
Support Zone during the conductance of site operations. This data sheet will accompany any personnel when medical
assistance is needed or if transport to a medical service facility is required:

Site:__________________________________________________________________________
Name:___________________________________________Home Telephone: ____________________
Address:______________________________________________________________________________
_____________________________________________________________________________________
Age: ______________ Height: ______________ Weight: ________________
Person to Contact in Case of Emergency:
_______________________________________________________ Phone No. ___________________
Drug or other Allergies: _________________________________________________________________
Particular Sensitivities: __________________________________________________________________
Do You Wear Contacts? YES NO
Provide a Checklist of Previous Illnesses or Exposures to Hazardous Chemicals:
_____________________________________________________________________________________
What Medications are you presently using? __________________________________________________
_____________________________________________________________________________________
Do you have any Medical Restriction? ______________________________________________________
_____________________________________________________________________________________
Name, Address, and Phone Number of Personal Physician:
______________________________________________________________________________________
______________________________________________________________________________________

APPENDIX D
EMERGENCY CONTACT INFORMATION
ESP ASSOCIATES, INC. – PARKWOOD STATION SITE

EMERGENCY INFORMATION
Agency, Contact, Facility Name Phone Number Hospital Directions Attached

Local Police:

911 Carolinas Medical Center - Mercy
2001 Vail Avenue
Fire Department:

911

Charlotte, NC 28207
(Hospital)

Novant Health Urgent Care &
Occupational Medicine
445 S. Kings Drive
Charlotte, NC 28207
(Urgent Care)
Ambulance:

911
Urgent Care Facility:
M-F 8-8, Sat-Sun 8-4
704-384-1734
Local Hospital: Wesley Long Hospital

704-304-5000

Health and Safety Officer:
Anthony White
704-309-5548
(Cell)
Site Manager:
Chris Ward
704-506-7618
(Cell)

***Post this information in a conspicuous place at the site***

***Retain this form in the project files***
11/14/2016 Industrial Sign & Graphics, Inc. to Carolinas Medical Center­Mercy ­ Google Maps
https://www.google.com/maps/dir/Industrial+Sign+%26+Graphics,+Inc.,+North+Brevard+Street,+Charlotte,+NC/Carolinas+Medical+Center­Mercy,+2001+V...1/1
Map data ©2016 Google 1000 ft
These directions are for planning purposes only. You may 䐘�nd that construction projects,
traf䐘�c, weather, or other events may cause conditions to differ from the map results, and you
should plan your route accordingly. You must obey all signs or notices regarding your route.
1702 North Brevard Street, Charlotte, NC 28206
2001 Vail Avenue, Charlotte, NC 28207
Industrial Sign & Graphics, Inc.
1.Head southwest on N Brevard St toward E 20th St
2.Turn left onto Parkwood Ave
3.Turn right onto Hawthorne Ln
4.Turn left onto E 5th St
5.Turn right onto N Caswell Rd
6.Turn left onto Vail Ave
Destination will be on the left
Carolinas Medical Center-Mercy
364 ft
0.7 mi
1.6 mi
0.2 mi
0.1 mi
0.1 mi
Drive 2.9 miles, 9 minIndustrial Sign & Graphics, Inc. to Carolinas Medical
Center-Mercy

APPENDIX D

APPENDIX D

APPENDIX D

APPENDIX D

APPENDIX E

INCIDENT REPORT

Person Completing This Report Phone Number ( )
Date of Report Date of Incident
month/day/year month/day/year
Employee’s Information:
Name Home Office
Occupation/Job Title

Where did the incident occur?

What was the employee doing when the incident occurred?

What was the type of injury or illness?

What object or substance directly harmed the employee?

800.960.7317
www.espassociates.com
Raleigh
5121 Kingdom Way
Suite 208
Raleigh, NC 27607
919.678.1070
ESP Corporate Offi ce
3475 Lakemont Boulevard
Fort Mill, South Carolina 29708
803.802.2440
Mailing
PO Box 7030
Charlotte, North Carolina 28241
Concord
7144 Weddington Rd., NW
Suite 110
Concord, NC 28027
704.793.9855
Lake Norman
20484 Chartwell Center Dr.
Suite D
Cornelius, NC 28031
704.649.2863
Greensboro
7011 Albert Pick Rd.
Suite E
Greensboro, NC 27409
336.334.7724
Columbia
2711 Alpine Rd.
Suite 200
Columbia, SC 29223
803.705.2229
Wilmington
211 Racine Drive
Suite 101
Wilmington, NC 28403
910.313.6648
Pittsburgh
One Williamsburg Place
Suite G-5, Box 13
Warrendale, PA 15086
724.462.6606
Indianapolis
8673 Bash Street
Indianapolis, IN 46256
317.537.6979
Tampa
5455 W. Waters Avenue
Suite 210
Tampa, FL 33634
813.314.2662
Nashville
500 Wilson Pike Circle
Suite 310
Brentwood, TN 37027
615.760.8300