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W <br /> SAY JO?QLZ`f COL?v= =N 20��L� _A.., =?Li= DItiZSiON <br /> SI I:z• =?i-i_ A V'i S�'�Y <br /> ?_.R" i PA-RTII <br /> C_V SAL S.= 2ir0 �tON/"y� JM4C=-, <br /> ILAMON OF POT---N AL F-5 ARDS <br /> Sice Name: N « Lil ^a="� <br /> Address: w C. aoge s' <br /> Comma ?4=0n: Ptone Na.4-L� C 1 Co=osrres: <br /> Sweeps Number. -y, /) A 7/ f 1 Dur: <br /> proposed Dare of i+vesmgacon/sPecom [ j = .iosives: <br /> ar�a ies- <br /> ? DesCDrion and brie?.^z--:ve of ssne^on ac: i7 y. ( ] Inazo�c Cases: <br /> [ t New US r^smilazon [j UAR Im7ergzdan [j Me•=r <br /> [ 1 'ars Cosur in ?!ace [] -anirm pe Rmair [I Caid'=='S: <br /> [✓-ars/Pipe R-_oval [j 3e----vat oa C l °C3,r. <br /> [ ] i:srallarion or 3or zgs/Maniror=,g Weis <br /> PART M <br /> 3. Soe-^'c Site r^;pr_arc, P,-CQTJ= P SON?l PROfC.i�T <br /> _ter No_ Tzmk Czpac^/ 3.+� EQiTi?'N.^TiL <br /> Cme^ _. Y[a •mr=g _o�apIIen= (IIore: Mcni or`g <br /> / 1 .^_.^.S �^.•S. ..Oe Usec :Or all oPe^-7-pLS <br /> _= <br /> ;peo OneCs:cCJi[,w(c.r^ �S- DrJD:ace?..Connie or eyCo= ace <br /> _. Rei-se :smr . [Combus.-Dle Cu/C=,g Mere: <br /> vidence or leans/sail core'-� on [ ] [ 7 � i 1 Dere'--or -ubes (Seems/) <br /> Doc-=--A CroLCw^r_ COrrs.-,iearpn: f j ?-ES f NO [ ] Phocoio •L�=COC OeL'Cor <br /> 1-7zaC,-,m ,-d and pesatmon or '•=y-previous _^.ve=g=on [I Crs-a=c Vapor P17ze= <br /> or iacdenc [ ] Otre , specy. <br /> nim. g _sem—e^� are _oc sed, <br /> rrar.zie or acvtrr/zr-a rest =_`ors: <br /> 5. Plo SZ-e-7 <br /> znd Sa:e <br /> ?��i Gace_�-: (c^_ec ail :ar avoip & <br /> �j at or Coid Stress: ac (riga —i—ce_.v.) <br /> ( Noise Sai:r_ 2 p--a P oce--ve =^uvme^ / <br /> L J Cry= Dedcent]: T 4 Proce=on: [ ]A C IB [ IC (Gid <br /> o <br /> C l F cavarion: ( , crams siippir cave-ins) �- har. <br /> ( j angling and .zrsfer of&H-a=rdous Substance [ S 7 zsses/goggies <br /> (1=e, e-piosiors, ec--) [a_,. coed/s:aas shoes or boon <br /> [ 7 g4finned Soace e^.--r (emissions) C I :zme rerardanr coveals <br /> w equipmenr (paysic jury g - --a resuinng C 1 Her=g prorecen <br /> =om =ov ng ^sivme=r) C 1 77vek <br /> [ j Respiracar, c-de: APR or SCT3A <br /> [ 1 Ocher, specify A/D c=-d- <br /> [ j Safery ver <br /> 7. ?_ricpared 3ioiogirl :z=&. [ I T O-WZ7 cot_u i oc <br /> f j Smites [ ] �'rseccs [ ] Roden [ ] Poisonous ?Sana <br /> L 1 Occer/Lini=own (spe=ry): PART iV <br /> PLP14 APPROVAL <br /> 8. Narrative (provide a1 _*or-arias wimk:- couid �mpac e e 1= <br /> and Safety, a g., power des, inrar 7 of dices, :-•--^,n dr,-): o!= prepared b5. Daze: y, <br /> ?!z=Approved by. DauZF <br /> =_3O8i iJi/S2) <br />