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SA ti .i 0?QLL`r COL?-1v =VV :711)ItiZSiON <br /> SIT= HEALTH A-V7D S?�T pL_ <br /> P�A�Rr�t o-ILP <br /> `-^.�ti.�il..=mIIvrORM?.TiOjN/ ITU <br /> EVALMA..=ON OF POT=huAL HAZARDS <br /> :. Sire Nacre: WQi¢/le 41 finstne.1�.p�d- i- Che=icu -r'aares <br /> Address: RQQ /} . l/ 4 A N�92.0 <br /> CPnma person: pyo �(,�]nC`-rcrogs: <br /> ane No. Zy CaIszs: s: <br /> Swee?s NLabe=. ���: <br /> Prr000sed Dare of rvesdgzcon/�spe moa �l© [ ] =rplosives- <br /> (I r Imm,h!es: <br /> 2 Descpdon and 'oris na=dive of Tsoe�or- act-mry: ( ] Lor.-a--;c Gases: <br /> [ 1 New UST r„S=nacon [] UAR lnve:Mg on <br /> ( 1 - nCor + ? Tank/10-?e was <br /> ( ] C ] Oadi_z <br /> ( ] -a=k/?ipe Removal 3e r±csvacon [] PGs- <br /> [ ] -smlaion or-Bo W n <br /> 'K Hqz Umsrc PART ME <br /> 3. Spec.,"k Sire I_;o:-_.acor: REQGmm PERSON?S.PROI=GIVE <br /> to. Tzn:,c Capacirr. EQUiPNi <br /> Tank Corre-a: Tank Age: <br /> Corer' _- Monrrormg =autmenL (none: molmiror�' g <br /> 0 <br /> _ype of Operator-: /I L]OJs a? / X// ,Fess a?prop=are zcona a arcs c=ots are <br /> Provide <br /> S. R° ease F smr/ [ j Conbuseole Gas/Omen Me:° <br /> vide=ce of leaks/soil copra-,imadoc: I 'S ( ] NO ( ] Dere=r-Tabes (Sees^7) <br /> Doc,-+eared Gros:dware- corr,,;racon: [ <br /> 1 -� ( ] NO ( ] Phocoioni-don Derecor <br /> Back;-o—d and des=r? on of any previous =ves-dgzcon (I Crzic Vapor?=iyze- <br /> or incdence: ( 1 Or=es speciy <br /> u=oniro, g*— ^� are =oc _sed <br /> z^'acme or ac*iviq/area reser <br /> 5. Pocenea rear= and Safer/ <br /> PhYsic_l Conr all ci:ar apply & descDe) <br /> ](rear or Cold Stress: >/64 PF Cnrgn arcibien, r�D.) <br /> r ] Noise Source- 2 Persona proceave :zur;me- <br /> ( 1 Or e? De=cent. <br /> Ig l Level of Pyre^'on (lA CIE C IC <br /> ( 7 =-ravzcon (fats, s flippigcves)n , zrd bar <br /> ( I ranaling and Transfer of a Fa=trcioas Subs=ce: MLSafery ices/gogtes <br /> (E e, expiasians, ere) ( I Steel. coed/s"az k shoes or boors <br /> C ] Coned Soar_ erL3r- (expiosions) (j -=e remrdanr covers <br /> eavv egtripne=r (piryrc zjruy& ¢a*r a resalring >Kg mmrec=on <br /> _oC moving Tyvek <br /> ( I Respirator, ace: APR or SC BA <br /> [ 1 Oc+se', specify ?✓P cr=dge- <br /> Saiery ver. <br /> 7. A_ricpaced BioiogicE Fa=ds-. k)p JVE ( I Two-way com-c-ai¢rion <br /> [ j Snakes C 1 Lseccs ( ] Rodents ( I Poisonous Plana <br /> ( ] OchneL/Umimowm (specify): PART N <br /> PLAN APPROVAL <br /> 8. Nax- -dve (provide aR in:or_acon which could irrapac-i yea t <br /> and Safety, eg., powerL^es, inLegrsy of dikes, rL_Jir; ere): ?!an Prepzred S ?rteOQ <br /> Plzn Smproveedd by. _ Dare l P> <br />