DEP WORKSITE HAZARD ASSESSMENT

PART A Site Name: Blue Ridge Landfill AI #: 998	Incident #:
This form must be started before a site visit and considered during the site visit, as worksite conditions change or as new conditions are discovered, but remain incomplete and unsigned until after the site visit is concluded. This will help ensure your safety and health. Description of Activities: Solid waste inspection in conjunction with a TENORM investigation.
PART B Check the hazard(s) located at the site being assessed sufficient to require Personal Protection Equipment (PPE).
TORSO/WHOLE BODY LIKELY INJURY/HAZARD Cut/Abrasion/Puncture Electrical Chemical Biological Temperature Struck By/Against Body Fluids Strain Cumulative Slip/Trip/Fall Same Level Fall (A) Different Level Fall (B) Entrapment Immersion, Submersion, Water Permit Required Confined Space Other________________	29 CFR 1910. MISC. STANDARDS - TORSO/WHOLE BODY Adequate clothing NO GO or maintain safe distance Review MSDS and determine proper PPE Proper clothing/barrier, cream/repellant Cold-insulated jacket/coat, heat-appropriate clothing, work/rest intervals Protective clothing, warning devices, guards Protective apron/coveralls review BBP Plan Proper work habit, assistance, appropriate tools Body mechanics, proper tools, workstations Proper footwear, harness/tether/lifeline, assistance Same as # 10 (A) Same as # 10 (B) NO GO - Do not enter Personal flotation device, tether/lifeline NO GO Call supervisor/branch manager/and/or ERT
HEAD LIKELY INJURY/HAZARD Struck By Struck Against Electrical Temperature Other_______________	29 CFR 1910.135 HEAD PPE Hard hat Hard hat NO GO – Maintain distance Hard hat with winter liner or sweat band, cooling device as required Call supervisor, branch manager and/or ERT
EYES/FACE LIKELY INJURY/HAZARD Airborne Chemical Flash/Light/UV Other _________________	29 CFR 1910.133 EYES/FACE PPE Safety goggles with side shields, goggles or full face shield for hazard Review MSDS and determine appropriate eyewear and beware of any respiratory hazard Non-vented goggles or full face shield filter or tinted lens and sunscreen for sun exposure Call supervisor, branch manager and/or ERT
RESPIRATORY LIKELY INJURY/HAZARD Oxygen Deficiency Airborne Particles Dusts Fumes Mists Airborne Contaminants Gases Vapors Combinations Temperature Other _________________	29 CFR 1910.134 RESPIRATORY PPE NO GO NO GO unless in DEP Respiratory Protection Program (RPP) OR unless respiratory hazard can be avoided (explain) Same as #2 Same as #2 Same as #2 Same as #2 Same as #2 Same as #2 Same as #2 Cold temps - cover mouth/nose, Hot temps - SCBA or supplied air (tempered) Call supervisor/branch manager and/or ERT NOTE: If in the RPP follow proper respirator selection protocols and procedures for any item checked above.
HAND/ARM LIKELY INJURY/HAZARD Cut/Abrasion/Puncture Electrical Chemical Biological Temperature Sunburn Body Fluids Cumulative Strain Other________________	29 CFR 1910.138 HAND/ARM PPE Gloves - canvas, leather, mesh, Kevlar NO GO or maintain safe distance Review MSDS and determine appropriate gloves/sleeves or coveralls Clothing/gloves/coveralls/barrier cream repellant Gloves/clothing Wear long sleeves, gloves or sunscreen Latex/nitrile gloves (review Bloodborne Pathogen Plan - BBP) Gloves/restraints Adequate tools/assistance from others Call supervisor/branch manager and/or ERT
FOOT/LEG LIKELY INJURY/HAZARD Cut/Abrasion/Puncture Electrical Chemical Biological Temperature Struck By/Against Strain Other_________________	29 CFR 1910.136 FOOT/LEG PPE Approved safety shoe, proper clothing NO GO or maintain safe distance Review MSDS and determine proper PPE Coverall/barrier cream/repellant Insulated footwear, clothing adequate for hazard Safety shoes, adequate clothing, proper techniques Adequate tools, assistance from others Call supervisor/branch manager and/or ERT
AUDITORY NOISE LEVEL Ambient Level above 85 dBA Impact Level above 85 dBA Other ___________________ NOTE: Noise level rule of thumb: If you are within 2-3 feet of someone and you have to yell to communicate you are above 85 dBA.	29 CFR 1910.95 HEARING PROTECTION Appropriate NRR ear plugs or muffs Appropriate NRR ear plugs or muffs Call supervisor/ branch manager and/or ERT
PART C GO: NO GO: I will follow the recommendation found in the right column above for each hazard checked in the left column above. If exceptions, contact your supervisor. COMMENTS: Very cold and windy; frozen ground. Dress warm and watch your step on the frozen, uneven ground.
PART D NOTE: Any NO GO situation witnessed should prompt immediate notification to your supervisor, branch manager, and/or the DEP’s Emergency Response Center, (800) 928-2380, for further assessment and possible emergency declaration/contracting. (Optional)SUPERVISOR: I have reviewed this document with the employee to discuss responsible safety measures, equipment and techniques. ________________________________________ ________________________ (Optional) Supervisor Signature Date EMPLOYEE CERTIFICATION: I certify this WORKSITE HAZARD ASSESSMENT was conducted, reviewed and/or updated. Appropriate Personal Protective Equipment was utilized per hazards noted or anticipated. ________________________________________ 2/10/16 George Weems Employee Signature Date

NOTES:

If you need to refer a facility to OSHA for specific questions or conditions:

Kentucky Labor Cabinet, 1047 US Hwy 127 South, Suite 4, Frankfort, KY 40601

502-564-3070 – Phone

502-564-5387 – Fax