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SA Ni 10a QULN C0TJW. 7Y EVV'tON?IENA.: , Ir Ms,L,l-z 1 DIVISION <br />SZ % r' � A LT"3 A -N -D SAFEETI Y PLA�i <br />GE,NE-AI. SL:z. I1V-FORMA%sON <br />_. Site Nayej� <br />- <br />Add_less• <br />Contac ?e_ -son: _ Phone No <br />Sweeps Numbe_-: <br />Proposed Date or =vest:gamon/Inspe ton: <br />2. Desawrion and brief nat-at:ve of irspe^'on acti my <br />[ 1 New USTI l i at:on [ J UAR Iaves gazion <br />(1 Tank (Zoszt:e i : Place (] Tank/Pipe Imair <br />[ I Tamk/Pipe Re -m -oval (] R e--=cavation <br />(J L-stzlanon of 3or�=gs/Moniro=g Weals <br />3. <br />Spec?^c Site <br />ank No. <br />i ank Conte.^_ts: <br />Ct.'ier: <br />TankC mach <br />L ank A;e_ <br />- <br />-r. Type of Ope_^atiod: <br />3. ? elelse I-storf: <br />,ridence of leaks/soil cont<*^inarion: (j 'r= 5 [ ] NO <br />Doc menred Groundwater contamination: (j `ES (j NO <br />3ack,ound and desc':pt_on of azry previous .^_ves`;arion <br />or inc:deace: <br />5. Poce_^_tial ^ealt and Sate^/ <br />?�ysical Conc=--s: (cheer ail far appiy & desc-De) <br />( I rear or Coid Suess: of (high atr_bierr m --p.) <br />[ I Noise Source: <br />( i Oxygen De*?k�ercq: <br />] _ Travarion: (fad, 4 ps ,Sapping cave-ins) <br />(J ;:angling and Transfer of a i-:a=rdous Substance: <br />(� <br />-e, e=iosiors, etc-) <br />(I Confined Space e^.=7: (expiosions) <br />f ] =eavy e=pmert (Physical injury & "a=a resulting <br />ora covmg equiprne=ej <br />(I Other, specify <br />i. Anticipated 3iologiczt '.aids: <br />[ j Snakes ( i Insects C ] Rodents [ ] Poisonous Plants <br />[ ] Other/UmL mown (specify): <br />8. Narrative (provide a1? information which could b3pac Health <br />and Saie_ry, e ;-, powe_- lies, inte-,--'rl of d=ices, cerin, eec-): <br />=F23081 (2/7/92) <br />PART II <br />FV <br />ALUA=ON OF POT -N—L AL i--AZARDS <br />1. -**'call 'riaZrds <br />yto'! Casio gens: <br />( I Cot:; osives- <br />C I Du=: <br />[ _ -- losives: . <br />( I Inorgacic Gases: <br />[ I Me = -;s: <br />C 1 Oath --_-s: <br />[ l PC3's: <br />PART I <br />REQUIRED PE—RSONAL PR=.mCME <br />EQU�M�i"i <br />Moaitormg=cuiDaie-mr: (nate: Monitorn g <br />==emts must be used for aL ope_a ons <br />uniess appropriate meonaie ores=:crony are <br />provided <br />[ I CatabirDle Gas/Osyge-- Merer <br />(I De_ecor Tabes (Specify) <br />[ I Photoio T"t:on Decec'or <br />[ j Cr;=ic Vapor snaiyze- <br />[ ] Otte-, specirr. <br />If =onto, ;—g =,s—==e= are mot sea, <br />zr=orale or activity /area resaic=ors: <br />? Pe_=onal Prote--ve ...gmpmenr <br />T vel of Prore ton: C ]A C IB [ IC [ ID <br />Ir[ I am aat <br />e_-7 giasses/goggies <br />T tee' coed/shank shoes or boots. <br />I same retardant cove_raIls <br />[ J c?ear-ing =orecron <br />C I 77vek <br />[ I Rerpiraror, circle: APR or SC3A <br />A/P ca. —,--d—1 -- <br />[ j Safey vest <br />[ I Two=rvay cotr.WLnicaion <br />PART r <br />PI AN APPROVAL <br />Plan Prepared by Date: <br />Pray approved by- Dare: <br />