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S�ti JOAQLLN COTi`: =VV120iv�1~v Ai =A=L.H DI47SION <br /> SIT= ;~�A-LTR AND SAFE= PLAN <br /> ?ART i PART 11 <br /> C�IERAI SI—Im U,;FORMAIION EVALUATION OF POTv uAL F1i7-1RDS <br /> 1. Sire Name: a.,jik1. Ct�icals "r'aaas <br /> .Address: [�Mcmoge=: <br /> ConaC Person: Phone No. (j Cacosives: <br /> Sweeps Number. PR S f 3A D [y'husts: <br /> Proposed Dare of mvesrig;mc=A =e con: _ C I E=losives: <br /> 2 Descpdon and brief nz�-acive of hzme=on ac-Var. [ j inorganic Cases: <br /> [ 1 New GS s.Llacoa C ] &A-R, Inveszgarion C j Mezais: <br /> ( 1 tank Cosr=_ s ?lace [ 7 -ar_k/P a 3epas <br /> amk/Pipe Removal C I Re-ttcavarion []PC3's: <br /> [ j in salla=on of 3or=gs/Monirortng Wells <br /> PART S <br /> 3. Soe if c Site I.%o^_ario= REQrj= P--RSONPSL,PROTECTIVE <br /> Harr Vo. Y -aJK ca acry 1(g,b %� A0,0&0 <br /> EQULpM I <br /> -aEr Cone-= LLL Tahx Py <br /> Other: I. MoaiLori?g Equipment: (note: Mcmiroring <br /> ? —,.=z be used for ail ooe_^a=ons <br /> -y.a of Ope_riot / h/_�-r'�_ L�ia� M L,--7lss appropr'are na no nad a or-es=-cars are <br /> orovideaE) <br /> S. Reiierse H_szorr. XCombusaole Cas/Ox7gan Meer <br /> Evidence OF leiYs/soil COT!"EMin>ripn: [ ] ?j VO ( ] Dere=or Tabes (Speer/) <br /> Doc- - --red Groundwam- con'..a-inacon: C j `r-5 XNO [ ] Phocoionsacoa Dececpr <br /> Bac: roid and des=con of any previous _^vesagacoa [I Organic Vapor?ri7cer <br /> or i didence: [ 7 Other, s?eCify: <br /> If monico. g 'S1L.ena l*e =oc led, <br /> Lz++oraie or ac-*virr/zrea reser cors: <br /> 5. Pocehaal H-air= and Safety <br /> Physi Cancer--s: (c=ep_• all ,:ar appiy & dsebe) <br /> or Coid Stress: °F (high, amhie-,Le2^'a.) <br /> Noise Source: R& G 1 D p_ 2 Personal ?rocecve auomenr <br /> C 1 Oxjr-n De=cency Leve! of P pee^on [ ]A C JB C IC VID <br /> ,XESCavanon: =s ,siippm& Cave-ms) >�:2rQ bar VN <br /> C ] Handling and raasfer of a razardous Substance Safety gia-ss/gogls <br /> (E., espiosions, etc) Steel. coed/shaak shoes or boors <br /> [ ] Condned Soace ez*y: Cespicsions) ( j Flame recar3ant cove-rails <br /> C j Heavy equipment (Physical <br /> Nml(pu�ryn m resulting X.Hearag?=recon <br /> from roving N.1_ai'pL^e=r) C�yi R A)EL [ j Tyvek <br /> [ ] Respirator, ride: APR or SC3A <br /> [ j Odher, specify A/P caz=dge: <br /> XSaiery vest <br /> 7. Anticipated Biological 'raz_ds: IU&YAA- C ] Two-way COI.L'1Lh=MOa <br /> [ j Snakes [ ] insects C ] Rodents ( I Poisonous ?lana <br /> C I Ochet/UnImown (specy): ?ART IV <br /> PLAN APPROVAL <br /> S. Nar-narive (provide al icormarion which could hapac:Heal <br /> and Saie_ry, a;.n Powe: L--es, ihre .±y of dixs, :e_--airs, etc): Plan Prepared Syzj Dare: <br /> >=an�cC.� atiea.. <br /> Plzr oorovec by: Daze: <br /> '23081 C2/7/521, <br />