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yid <br />SAN 10AQU W COTJN i Y LVVLRONQYJE +' AI. =E - L DD-rSION <br />SITZ HE-kL7zl AND SAFE PL3LNT <br />ART I <br />C'`iEiBL SMLZ aqF'ORMA=CN <br />ART II <br />EVALITi+:IICN OF PO-C'�-.YMAL HAZARDS <br />sire Mame: l;4.m- 6wbbcrj I - <br />Address a <br />If - <br />Comm= Pers n: Jirh� VJ ,-C b Phone No -may 64TY33� <br />Sweeps Numbs_ ZA 1 D 90 <br />Proposed Date or in7esdgadaa/9spec0a: <br />? Descpdon and brief zstdve of =soeroa acviry: <br />[ 1 Nev GST� an [ I &AR Iavesc3adoa <br />C 1 Tank Coss-- = Place [ ] Taak/?!pe Repair <br />[ara/Pipe Rd=ov-ai (] de ,-=moa <br />f 1 in=17adoa of 3orr.�cniroy= weds <br />(�anis F'azi-ds <br />Gz�agers: _ <br />C I Cacps ves: _ <br />C I Dusm <br />C1 Ta Ies:_ <br />CI [aorraric Gases: <br />C I Mems: <br />C I C=ai----s: <br />C 1 Pa'= <br />PART dI <br />3_ Sce_dc Site Lror:madoa <br />3-QLIRE' PW—RS.7N.A.L mcm-GIVE <br />Tank Vo. _ T=ax C_�acy <br />=QUIPl1fYi <br />Tank Canr Tank Ag--• tAl��. <br />Crher. <br />1, Maaimrj-+g Equiurawm Cnote: Vor=torn.- <br />�e aur, ie used or aA apendars <br />1. Type of Cpe--r:oa: <br />a m=arace =o=e or=es—" -cons are <br />Prom <br />Eeiease ^story <br />cgtzmbusmio . Grs/Oxygen y[ete; <br />E9Ioe-Ce of le3_4=/S017 cmMM= majCjon: 1 ES fa <br />i I Der --=r Tapes (Soec,7) <br />c=m <br />Dace=ad C-rounawaa nn comnroa [ I MS C�c <br />C I Naaccioa��aa:)e,--=r <br />3ac—Ouad and desc#t oa of any ;r--Moi:s=vesd,-=CXL <br />v.= <br />C I Or amc Vapor Anziyzer <br />or incidence: <br />C I O *�. S?eci'T- <br />=acicor=g =sem ^P^+! an oc _sed, <br />nsdaraie or acv=7 /u --z res, -:cans: <br />5. ?acenrai eala and Saft-7 <br />Phyllcmi Cance=: Cce�s ail L-= apply & desc.:e) <br />(ear or Chid Ssess: <br />W-Ncise Source: <br />Z. °--=nai .0-00!4=7a E?M=e=r <br />C I Cxyg-n De=dMMc/ <br />or Prote=an: C IA C IB C IC ?Tt <br />(WS, sps siiapia; cave -=s) <br />( aac <br />&4- cradling and T.ransfc or a r-+� =us Sabscanc_ <br />(FIBS " 7 rasses/;p es <br />(lir-_ expiosions, a=) <br />Steil med/shaaic Shoes or boots <br />[ ] ;oadaed Space em=/ Cemiasioas) <br />C 1 'tee "'*== cove's <br />[ eavy e�ui- — (Physied =jury & == resairrmg <br />C 1 •�r�g protecaa <br />m laving quipmea) <br />C 1 T7 <br />C I qa:sqitamr, cce: '.PtL or SC3A <br />[ 7 Other, specry <br />Vo =:dgs- <br />C I Safety est <br />i. Acridaaced 3iologici : az=s <br />C ] i+w-:gray CM---Mmi=dan <br />C I Snakes C I lasecm C I Rod-- C I Poisonous ?tants <br />[ I Otcer/LTnic own Csyed[y): <br />PART W <br />PLAN APP4CVAL <br />S. Naracve (provide all i* r=adon which could �aG L-ryI <br />-k <br />D2L2 7i z o 7 <br />and Sare77, a... lower Lr•_es, :mm- 7 ar d, e=): <br />'-oy- <br />Piz; lmoraved by- Da-. : <br />MZCSi <br />