Laserfiche WebLink
s <br />0 <br />SA 1i s 0?_QLZN COUNT si E VIROIY!NaN —IIAL -�- AL.z H DEVISiON <br />Ste' ' AJ-TrI A.tiTD SAFETY L��N <br />? ART I <br />=. AL Sir'. IN-FORMA=ON <br />PART II <br />EV <br />AL=ON OF POT -N-11AL FORDS <br />01'L L <br />_. Sire Na_e: - <br />AddresS: fJ V y <br />Coara Person:kcN '1 EL() Phone No. JQ� y w Z <br />Sweeps N=ber.. <br />P-oposed Dare ofvesr:;aon/sae roti G z L <br />2. Des=-Deor< and "brie; :ia of ir_spe --Yoh ac:jviLy: <br />1 New US -I I_^saiiar=on [ ] UA.R ir:ves goon <br />(] 'ark C:osu-e i^ Place'pe _ air,,, <br />(] -'ank/Piae RP.�oval [ ] f <br />[ ] <br />ins=narion of 3or-gs/Moairor�ng Wells <br />�. Sae^'^`c Site 1--for-at?ca: <br />is k No. 7ay,k ConLerCs: <br />iype of Cgeraria= <br />T +t capaciry: <br />Tank Age: <br />j. 2 e_' _ase �"�SL❑r'f: <br />viderice of leaks/soil cnn aMan: ( ] ''ES (j NO <br />DOC-.me.m-ted (Zrouzmr- acar- coamminaCiO= ( I `rte (] NO <br />3ac'.:,v,mumd and des=-.Dz:or, of any previousi=ves-49=Oa <br />or incidence: <br />aemicais Hazards <br />V,CarCiaogens: <br />[ ] Ca�osives: <br />[� iosives: <br />[ I lnorga is Gases: <br />] Metals:. <br />C 1 Oar=z--Ts: <br />[ 7 PCTs: <br />P aA T iZ <br />RFQTJ-= P=—�SONAL PR=MC <br />FQULaNEw, <br />o L1Lar= �-:n=1DIIe" (nore: monicor - <br />iYSL ^a�*S =i:s4 be Use, 'or 2E, ope_a a= <br />L'�1e55 aDDrDar:are r oma a orare <br />?rovideii) <br />["1 0ombus:fble Metez- <br />(] Dere=or Tubes (Specify) <br />[ ; <br />0horoianT'z2r on Derecror <br />(] Or znic Vapor jay= <br />[ 1 Omer, specrr- <br />li ,maniror.t g '*' m er a_re Lorused, <br />m orale or acdvicy /area reser c=ars: <br />6- 'Poce-m-t l c':eallrn aid Sa:ertf <br />p�ysics Canc_=ail c ar apaly 3c dese;fle) <br />( nr 'Hear Or Chid j�:E'SS: 07 (`�gn amnlew LC_.m p. <br />} Noise SOL r`e: <br />2 Personal ?--are- <br />??rote mon [ ]A ( 1B C ] C [ ]D <br />( ] Osi/gen <br />Lege! o= <br />s ,siirming cave-ins)(�� <br />and har <br />:angling and Trans'er ai a F-azardous Sabsniacs: <br />V'Safe_*y gia=es/an des <br />(Ere, expiosior;s, etc; <br />coed/shnank shoes or boors <br />[ 1 Coed Space eat:y: Ce piosions) <br />( 1 :lame :etardan.t cone_ Ls*aL <br />f� :eav+r e= -D=e= Cphysi�! injury 3L V at�*�.a rwt'li=g <br />(1 ::ems, proLec-�on <br />torr moving -=47)Ment" <br />[ I Tyvek <br />(] Iesoirazor, circle: APR. or SC3A <br />,{!? Orhe_, specify L1fwr"'v6W V� <br />A/D c: ��:d;e: <br />(:.j"Sacety vest. <br />7. a^Ecipared 3ioiogic `r" --girds: <br />(I Two-Wy cot s�it~TM_'on <br />J Snakes (L^SCLTS [ ] Rodents [ 1 Poisonous Plants <br />( Oc' e_-/L�n.kiiown (speci y): <br />PP RT iV <br />— --' <br />p 4N APPROVAL <br />8 Nar arive (provide all ir-formadon which cote i=rpaa He31r-b <br />rbl G1 r� 1 f? Dace: <br />and Saze_ry, e g., Power lies, inregr r'l of dues, z;c-): <br />?lai Pre?aree by , <br />oia-r ADVMVed. by- Dare: <br />HH2308i (2/77/921, <br />