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CONFIDENTIAL <br />SA ti JO? QLZN COLTiTT Y EN VROhR!Y� 1 AL �. � ,:�j, . DIV ESiOt�i <br />S== �'!- 1 Z't1 AND SA -T' PL k y <br />?SRT 1 <br />C^�- aAL INFORB&k=ON <br />Site Na` -+e: CA N 4 4-6*1 69v 4rfj <br />Address: Ab2,0 S. 4k w- <br />Contac ?e_ -son: Phone No. f. <br />Sweevs Nuaber,. <br />Pr000sed Date ofvest�t:orJ�r^s�ec <br />2. Desc:Ddon and brier nararrve of imspe =on ac=vitt': <br />[ 1 New UST T-szzilarson <br />[ J UAR lavesr gman <br />[ 1 Tank Closu:-e it Plan_ <br />(] Tank/P:pe Repair <br />[ ] .a-K/Pipe R --oval <br />(] �e-��c;vzt:on <br />(] irstallamon or 3ori—p/Monirorng Wells <br />C� 4v-' (:A wr+N\ <br />3. Scec:.^c Site TL-fo*'t'r'ot=' <br />-a.-K No. <br />TavK Capad-T. <br />TanK Contents: <br />Ta= Agp. <br />Ct:Ze_� <br />5. <br />Type of Cpe_-at:en: !" A 1+l <br />? eiease F:storr <br />ide=ce of learns/soil conmar"ima^on: [ J -fEs [ 1 NO <br />Doc-,*- eared Groundwater- conr---'1-ar oQ= ] ` ES [ ] NO <br />Bac ,,mound and desc-'ptam of amy previous investagar:oa <br />or indde^ce: <br />Pocear al ealry and Safery <br />?�ysical Concer, (c^_err ail far aDpiy & descDe) <br />,eat or Coid Suess: OF CRign aabier* te=p.) <br />.Noise Source: <br />(i Orygem Den de^ cr. <br />[ l j=vatlon: (fabs, siippino cave-ins) <br />:analin; and Transfer of a Hazardous Substance.- <br />(1?re, espiosiors, erc., <br />[ ] Conned Soac_ zr (emiosions) <br />f ] -e_vv eaumaenr (Physic=, injury & traLya resultmg <br />moor =0,7 g ecu r lemt) <br />(1 Oilier, spea*y <br />7. Anticipated HioiogiC::! razards: <br />[ f Snakes [ ] L --sects [ ] Rodents [ J Poisonous Plants <br />[ l OL-e_/Unlmown (specify): <br />S. NNar--arive (provide aLii inior--adon which coLid iapaG Healt1, <br />and Safe --y, e g-, power lies, inre�'r of d:.Kes, ?.e ---j= etc):: <br />=-"23081 (2/7/92) <br />PART U <br />EVALD:A=ON OF PC -r -� —1.LAL F-A.ZARDS <br />1. Che^.scals ra-2rGS <br />K C`-rdnoge^s: <br />,[Q Caroosives: <br />N Dusts: <br />(J=-losives: <br />F T Z==I es: <br />[ ] lno o7aI1c Cases' <br />Mems <br />[ I 0=iaiz—ers: <br />PG's: <br />PAR71, <br />REQTj= P=-4SONA1. PR.OT_'=L <br />t QULD'Li✓T�i <br />'_. MOLitor'?'g Equipme—m : (more: Moniror"in <br />crust be used for aii oDe-c=ors <br />,- ess appropr:ace raeonaie or=es= --=ors are <br />?rovidec� <br />(j Cocbun ole Cu/Ozyge_ Mere-- <br />(] De:ecor Tubes (Specify) <br />(� PTaocoio t arion Detecor <br />[ ] Crgp-ic Vapor Ayaiyze- <br />(] Otre_-, spec:rr. <br />It maniroryg�r •^e^.:S are not _sed, <br />rzTorsie or ac-- imr /area reser cors: <br />2. Personal Protec.-'ve.^uipme=r <br />L_ -vel of Prote mon: [ lA [ IR ( IC ( ]D <br />Q(i : -ard Rat <br />Saie_7 giz:ses/gogoies <br />J_ Stee_i coed/shank shoes or boors <br />[ 1 Kzm:e retardant covera..sa <br />=egg ?rorec-=on <br />( 1 L 7vek <br />[ j Raspir�faror, crde: APR or SC3A <br />`a V-nge: <br />Safe -7 vest <br />coaauni=tion <br />PART 1V <br />PLAN APPROVAL (� �f <br />Dlz ?rvoared by. P,4 Dare: -641-9 <br />?lan Approved by: � Dat_: <br />