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SAN 70AQULN COU-N-717 =VVLRO?v-kaV _L H A,i H DIVISION <br /> SIT- =- �ki?-H 4-V7D Sri. 1 Y j?]_AN <br /> PART i PART LI <br /> G-n ' AL SI= 27rORN=ON EVALMAIION OF PO"L=N-E AL FAZ-%SDS <br /> _. Site Na-me: 1. X- <br /> C• P�lc In <br /> Address' �y' —=Caog--s: <br /> Comae Pe_^son: Phone Bio. CI Cocos yes: <br /> Sweeps Nuabe_. ( I Dusts: <br /> Pr000sec Dare of C I Z-losives: <br /> CI Flarzz abies: <br /> 2. Des^pdar and brie -=,--ve of xspe^on ae=vzy C 1 Cconan:c Gases: <br /> [ 1 New UST L ssIlacon C I UAR !nveszg on (I Metes: <br /> [ i TnCor�e im ? ace ake es Oxid e_-s- <br /> ( ] -a_VEN-ae R•.=oval ( I :Re--::cavztan [] PC3,s: <br /> ( ] Lem),Iadon of 3or^as/Monkarag Wells <br /> 0 h'i.l 5GMo lti-� - PARI M <br /> 3. Soe=^c Site 1_a=zrio^ tLQLKRFD PSLJN?l PROT_'CIIVr. <br /> ar <br /> _k No. . — ' Gpac y EQUG)1 <br /> Tank Canre_^rs: Tani Ag° <br /> OC1eI: _. Maa,:tor*•g _ainaerL (more: Mo TL'Lar*=g <br /> =usz be used Car ad-I opez-a--cm- <br /> 4. <br /> ,Voe CC cue--a--C= •unless aDProurace ZCana!e or-w=--c--c=are <br /> C provide') <br /> ace se Flory- C j Cocbusole Gas/Or/ger Meter <br /> =•ridence of leaks/sail carr-^•in"ior: ( I YS014 <br /> O [ ] De:e--ar Tubes (Spec^/) <br /> Doc—me-red Gro�dwacer conrvainarion: [ j YSS O ( ] Phoroior; -•LioII Derecror <br /> 3ackg orad =d aescpcor of any previous _vesdgacon [] Or,-is Vapor?=iryL <br /> or^ccence: [ 11 Ot*ez, specry: <br /> if aoniro. g ^s =ems z e =or zsec, <br /> z^'or=ie or a- <br /> -=Miry/zrea reser cars: <br /> 5. Poc_^eal -ealL and Safer/ <br /> Physial Cant--: Cc:-e---r ail d:ar appiy & descoe) <br /> ( ] -eat or cold Suess: ° (nigh axaien te=.p.) <br /> ( ] Noise Source: 2 Pe_-sonzl ?ncecve .^uipmenr* <br /> C 1 0,/gen DeLcencr Level of Protec:ios (IA C Ia C IC C <br /> ( ) =usvacoc (.°u, =rps Tiippirg, cave-its) ( I Hard 'nar <br /> (�jf znaling and Transfer of a raardous Subsanc e p ra hes/ es <br /> 0 .i <br /> 'Ere, e.=iasiors, ere) Ste_ toed/sha k woes or boots <br /> C I Canned Soace e--=T. (espiosiars) ( j -me retzrdanc cove_a s <br /> ( I -eavv e?unnenr (paysic injury& tra*....a resulring C ] fearing ?rorec=on <br /> =am aov4.ng -.upper:) ( I T7vek <br /> ( ] ?e i=zror, title: ?PR or SQA <br /> [ t Other, speciy <br /> ( ] Safety ver <br /> 7. Aamcpaced Biologic=L Vo-way canrc:i¢dor <br /> C I Snakes [ I Insets C I Rodents ( I Poisonous Plants <br /> C I Oche-/Ua.mo•vn (specify): PART IV <br /> PLAN APPHOVAS <br /> S. ML-a*'ve (provide aRI zor�acoa which coir izrpae F:ea!&- <br /> and Safe-/, erg., powe -es, inreg#of eCKts, ter--pin, tre): Plan Prepared by: Date: 1 <br /> P!znApprovecor. / Dace: <br /> =s308I (22/7/921 <br />