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0 0 <br />SAN AN QUZ�' COU?V"s"`�r <br />SITS ��a..T T -H AN -0) SAHE.1 Y PLS�i <br />PART Z <br />C-ZN -AL S,.=x. IN-FORW710N <br />-. Sire dame: <br />4 <br />nix <br />Address: <br />COUMC: P55011'. Phone No.1a uIt <br />Sweeps Number: <br />.Proposed Dare or �ves'Caaz on%rSpec on: �• C � <br />?_ Oescrpdon and brier nzr-adve of 'rnec:'on ac! vi - <br />[ 1 clew [.USI Ls ' ar:oa [ ] UAR iuves'dgadon <br />(] <br />Tani: Gosure ;� P'.ac• [ 3 Taa_k�'D e fair <br />(] . ark/Dipe Rasroval [ l Vie-'-cnvzdon <br />[ I loss Lamon or Bor-gs/Nlonirarmg Wells <br />H— <br />;. Soe^Fc Site L -for a o <br />lank No. Taa_ C_:pacty <br />v&eon - <br />1li.� Lau- <br />- Ty.De of Opera CCG:, 1- <br />,,. �elea_se z",.iStol"f. <br />7-7lGence of leak/s& coz T^'n�' '^on: r -!:.S [ � <br />Doc^ eared GraLc vzcer can==,nadon: [ 1 `r=S [ I Ni0 <br />Back,gro , d and desciadon of any previous '�.vesdgadon <br />or Unc:de;ce: <br />pace- -'al eaiti a^_d Safec/ <br />?tzysic�i Cance_ --s (c e , ail .�.ar aapiy & descDe) <br />I OF ai ambieWr temt�.) <br />ti ar or Cold Suess: C <br />Oise Sour= <br />I Oifgetl rIe C e -Cj <br />I -=avation: (i-115: ti pS cave -i=) <br />(' ] =angling and ansfer of a 1 azardous Substlace: <br />(Er ezpiosiors, erc.) <br />[ ] C ed Soace end (esniosions) <br />: ] T :envy aquiptaeaz (PCYMC- ! =Jury & X1=3 rwWdng <br />o= :roving eat ipmerL) <br />(] Odaer, specify <br />i. A=icipa:ed Bioio9ic:2l Hgirds: <br />[ ] Saakes ( I Insects 11 Rodents [ I Poisanovs Plar-rs <br />[ I Ormer/Uaiiaioivn (specify): <br />8 ° iia-*Yardve (provide all 40=03nwaica cold "nae_ F -"sea" <br />and Safety, ac., power Les, intea,-:rf of d: -'es, :e�*-san, acc-): <br />=�?08 (2/7/92) <br />P ART B <br />E'VALIZ�ON OF PO'IENTiM F'= IRDS <br />CrIlgEicals 'r_a=arrs <br />Wczrc�aoge",: Ra <br />[ 1 Coc:osives: <br />C I Ems= <br />(] z:rPiosives: <br />{ 1= acles: <br />[ ] [aoroanic Gases: <br />L I Memo: <br />C I PC31: <br />PARA E <br />F,CQT.J= PrRSONAL PRC"i�CiiVE <br />EQUMEE <br />oniLOirg 'SLdpnle^c (nore: Monitor':,,- <br />-or <br />onitor': a <br />ls�= �-g x,,.=: 'De used or 2L ave -dors <br />,aiess appropra:e -zdonaie or res cors are <br />prOvid d) <br />[ ] Conou`ble GxNa y — Met= <br />] pece=or rubes (Specfl) <br />C I ?snotoior�2adan Oe:zc:or <br />[ 1 CrTabc Vapor?.pOWZe_r <br />] Orrer, spe&ry: <br />=onlroiy;�" '=2_^.L� are not <br />radonaie or ac--MqT /area <br />pe_,onal P:-OW"7e Er^uipme=n <br />Levy of - - re moa: C I� [ ]C [IID <br />aaL <br />[ aIe',y z=se5/� 9ieS <br />( ree_j zoed/Lznks.'aoes or boots <br />(] <br />:---=e re=dant cove -'a --s <br />C I : =esag pnrec=:on <br />CIT7M <br />[ I Res-�irator, Grcie: A_'R or 5C3A <br />A./P c--'dge' <br />[ I Szrery vest <br />[ I Two-way cota^unicadon <br />PART IV <br />PT VIr AgnR AVAl. <br />plan prepared by: Dare: v t <br />4 <br />J1 Zr pproveC <br />