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Sia �i MA I= C0T_jW_ 'Y EN_'-Va0N_ RY N ALT I=AI.7 DIVZSiON <br />S= r- � 4.L'7H AN -D SAFETY PLAN - <br />?ART i <br />P --".RT II <br />-:-: AL S<:� IN-FORMA=ON <br />EVALUA CN OF POT?v L AL HAZARDS <br />iQ4ad <br />1_ Cie-ieaIs Hazards <br />_. Site Name: <br />[j Czrccnoge_^_s: <br />Address:Q33 <br />Contac ?_'son: 14 • Phone No. 4'0 f <br />[ tcrrosives: <br />Sweeps N=be=.[,'YDS• <br />P-000sed Date of WiinAves c.adO spection: Ti':)7 /0 <br />[ I " =losives: <br />[erla�les: <br />2. Des=_Ddon and Drier -,Lz--a a o2 inspec..•-'on ac: Qvky <br />[ ] lmorog niic Cases: <br />(1 New UST T^ i at=on [ I UAR Inves-ganon <br />C.1 Mems: <br />[ 1 Tans Closure in Place [ I Tank/P.-pe Repair <br />[ l O�ddiz_-s: <br />[ I Tat=k/Pipe Removal((�. _ <br />' <br />[ ] PC3's: <br />[ ] lm i ation of 3or. gs/Mo ori els <br />??RT iz <br />R_QL=� Pr-2SON-Aj- Pr OL=C= <br />3. SOec-c Site I _formanO= <br />^�{ CzDaCty: <br />FQUEPML <br />Ta^ `C CanterrS: i -n K -- <br />'_. �/ omiror_;- � DIIe.^-L (note: O 'L�tOrl'! � <br />OLRe_- <br />;� • j m� =,=z be used or ail aoe_�mars <br />A. Type Operation: f 6itbfc <br />Mess appropriate znouaie or: —_=Ors are <br />of <br />oravided� <br />[ I Combus fble Gu/Ozy;p- Mete-- <br />leaks/soil con on: [ I '=-S [ I NO <br />[ ] Dere=or Tubes (Spey) <br />Svicer_ce of <br />Doc-=. GrOI=-dWat°_- co rmirat?on f j 'YES(] NO <br />[ 1, ?hotoio�t;on Deeec=or <br />Orua is Vapor Analyzer <br />3ac'tgrOund and desc_pdOa o any previous '.^.ves--taLlon <br />[ I <br />[ I Otae-, specify <br />or mc:derce: <br />If soniroryg��.s: -:me=ts are LOt•:sed, <br />znonale or ac:ir-77 /area res=,=O=: <br />5. Pocential -ea!t and Safery <br />?bysic--.1 Conca^.z: (cae-.r all t apply & desCDe) <br />[ ] meat or Cold S�ess: <br />_ <br />2. Personal P-ote�ve Equi pmenr <br />t, Noise Sour -ca: <br />C (1D <br />Level of P.-ote _on: [ ]A [ IR CIC <br />[ i Oxygen Detice^_c-- <br />[ ] = avaCon: (raid, wDs ,521, pin- cave-ins) <br />["1 r�Sd flat <br />( �; analin; and Transfer of a Hazardous Substance_• <br />[�}'Sare-'y glia sex/go les <br />boots <br />[4,SCee_i roed/shank shoes or <br />(bre, espiosiors, ere) <br />[ ] ^nine remrdanL cove_,a!!s <br />Fame <br />[ 11confinedSpace en=7- (exp oslOns) <br />eatuDme1 (physical injury & ria=a tzsulung <br />[ I -:e=r ng ?rotes=on <br />(..]�-eavv <br />[ j Tyne -k <br />om moving e�uuipaert) <br />[ I Respirator, Qce: APR or SC3A <br />(1 Other-, specify <br />AVP c=—�d;e: <br />[ ],/Sale y vest <br />'r?�--mss <br />(�J ;'�`ro-way communicrrion <br />a� v i -ter^ <br />i. ticpat_d 3iologic-=. <br />[ j Snakes [✓j L^seczs [ ] Ro ens [ I Poisonous Plants <br />p aRT IV <br />[�Otae_/Un->¢1o,.vn (spe iy): <br />PI -AN APPROVAL <br />8!Na---a&e (provide ai? or3a on which could mac_- Heal <br />P1z^_ Prepared by. 1�'► t" 24.' Date: 6 <br />and Safety, Wig., power- L^es, ' e�*xf of d aces, cirrus, erc): <br />?1a approved by Date: <br />l2/-//921, <br />