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( i <br /> S,r--N 10? LZ�t COL?vT;r EN- VLRON- NfE7 --tL, :=�Li= Diti-ISiON <br /> SIT^ TPEEIALTH .4-ND, <br /> ?ate7 . ?A-RT EE <br /> INrORMA:lob, E-VALIl4-2ON OF POT-N—IIiAL F-AZA=S <br /> _. Site Nate: ;o/f '- Ch SIS ^a-n <br /> Address: H [ -�oge= <br /> Comm=P_rson i °home No. �r-L• aa- ( r:osives: <br /> Sweevs NLabe:- C I its: <br /> Pr000sed Dare of *vest_;at: =A=e-t -- <br /> on: [ ] = iasives: <br /> 2_ DescDeoa and beer ^.ata a of^�spe:•_+oa ae'*vity: [ ] L^orc Cases: <br /> [ 1 New USIrs-. <br /> Ilat:oa [ J UAR <br /> Cliavergation [ uferis: <br /> [ i Tani Closure Place [ ] Ta -oe Rh' <br /> epa <br /> [ 1 -a^_k/Pipe 3�e-ova1 ( ] �e-�reivzz_oa <br /> ( I7-salla-don oof�,3ori gs/M nitar�g We-I <br /> r V`i - �%I W w K' ?ART u <br /> 3. oe-_^c Site Ir�o^ano_ R�QL F" PSONal. a?tC1iV� <br /> -__k No. - CGpac*v EQUL i <br /> -k Co=e^rs: Task Age.• <br /> uomitor- :gLiptae-_t: (Lace: Mc- tor'z; <br /> n ==—z be .sed :,Or ali ape_zcrs <br /> S 0 t' messaap��priare Zhorae or_e=--cors are <br /> ?- Mvideli) <br /> 5. 'Rei-ase ='_store C I C=bcst:ble Gas/Oaq;P- Me:e_- <br /> _91Ce_^_Ce o leaks/soil cam Dece—or 7Lbes ($cec*y) <br /> e.- ed Gia—cwate- co r—"raco= [ I YES C I NO [ I Photoioai '_mom Dete�ar <br /> Sac:;=atnd a^.d dese'_pt:oa t any?re rious =vesti;rsan [] Cy anic Vapor=2iy� <br /> or _nc:der:ce: C I Otter, specry: <br /> L=�arito.yg �s-_sen= are _ot _sed, <br /> _=_or-Ie or ac=*vitr/are=_ res'c_crs : <br /> 5. ?ace^_ha! e��t✓ and Safert/ <br /> ?�yrsic_I Conc__ms: (c_^e�?< aii t:zr appiy & descae) <br /> j =eat or Coid S=ess: °: (nim ambie^_f temp_) <br /> [ ] Noise Source: 2 Pe_sonal Protewe EgLi. --• <br /> [ i C--nen Oenc'_e=c•T: Level of P-ote-on: C]A C IB C IC <br /> C l vadom: (falls, ps 'SE ping, cave-i,$) [y�and 'bat <br /> 'Hamc2in- and of Ha=dous Substance: [afery aces/;odes <br /> 'Ere, =iosioms, erc.) [ �eei toed/s ark woes or boats <br /> [ ] Coa±aed Space e----T. ( iosions) <br /> arse :eda-_t cove_-a<'s <br /> f ] -eavv eau==r (Pays. ju=y& t:3L+aa resulting C ear*g pratec_ca <br /> =ort =oving spa=ert) C I T?ve' <br /> ( I Respirator, ccle: APR. or SGA <br /> ( ] S2ie_ry vest <br /> %. A�IICDared 310i0�c:2ii i'a1`�- [ J .."Vo-way c0^.�^L'11C=^Om <br /> [ I Sraa_kes [ 1, L^semis f ] g eats [ ] Poisonous Plants <br /> C I Oc:e_/Un o�vn <br /> (specify): PAR IV <br /> PL.s3�APPROVAL. <br /> 8. Nz_*�*ave (provide ail ia:or-_.a. 'on waicz couid �pac Health \ ( I <br /> and Safert/, Powe: Les, ' te;��* of a=ices, :e`--3in, trc): ?rz, Prepare_ by. v ' are: <br /> ?IL--1.00roved by. ,Dare: A <br /> "_308 i (?J7/92) • <br />