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SAINT IOA_QLIN COTJ= E:4 V',0_N_&IEV'rA_I FM L,T_u_ DIVISION <br /> SITE HE. I.TH . D SAI== PLA.Lv <br /> PART 1 PART U <br /> ca-NEq.Ai sr.—Lm INFORMATION EVALUATION OF POTEi'IIAL F-AZARDS <br /> 1. Sire dame: tL 1. Chcats 'r:azarcis <br /> Address: Q Wczr�ogens: <br /> Contac:P°rsan: Phone No. 'S t ('j C rrosives: <br /> Sweeps Number " <br /> Proposed Dare ofo1 gar: isaec:ion: ( j 1-^losives: _ <br /> 7 Descnipdon and brief aarradve of inspection acd icy-. ( j inorganic Gas : <br /> ( I New UST r l ron ( j UAR Investigadon <br /> ( I :anis Closure in ?lace [ j Tank/Pipe Repair (j adize_rs: <br /> Tank/Pipe Removal ( j Re-excavation [ .C3's: 7 } <br /> [ I installation of Borings/Monitoring Wells <br /> ?ART M <br /> 3. Sce-c Sire L-_1:oi=, adon: f QU�{ED PTERSONAL PROTECTIVE <br /> ::nk No. / 3-�� Tank Capacity (�� _QtT�MEYi <br /> Tan:�c Contents: - Tank Aga: <br /> Cr:.er: 1. Monirormg Equipment: (none: Manicorng <br /> must be used far all operations <br /> ?. Type of Ope_radoa: I uIIiess appropriate:adonaie or=es nicr:ons are <br /> p 'tied) <br /> 5. Release Hisror/- (VI Combustible Gas/Oxygen Mere~- <br /> 7W9idence of leaks/sod ccon: De_emor Tubes (Seedy) <br /> Doc-um-red Groundwater canraminadon: [ j MS [ I NO ( I PFocoionizat on Derector <br /> Back- and and des=prion of any previous investigation [j Or;aaic Vapor naiyzer <br /> or incidence.: [ j Orbe: specify: <br /> gad <br /> If-onirar ng ins,:menrs are uor;:sea, <br /> mdonaie or ac ivir//area res=`ie^ons: <br /> 6. Poce.^Iiai Health and Safe^( <br /> 06. ical Cance_^...s: (cher_'t ad chataaviy& desc be) <br /> �: <br /> ( e3c arl Cold LLess: ai. Chigh ambient carp.) <br /> ( Noise Source: 2 Personal Pzoce�ve Fxuipmenr <br /> [ I Csygen Deficie^^_c•/: -. Uvei of Proce cion: [IA [ IB [ IC <br /> (i?'�=C3vaLf on: (falls, YIDS jiippinl Cave-ins) Hard Qat <br /> [ j Handling and Transfer of a r'_azardous Substance: afety gasses/gog�,..es <br /> (Tlre, explosions, etc.) [ j Siee_l coed/shark shoes or boors <br /> ( j gonnned Space enny: (ezaiosions) (j Rame retardant coveralls <br /> (• Heavye=-Dme= (physicist jury& YaiimB resulting W. 'Ig proret�on <br /> =am moving equipmenr) h 6 e, Tpvek <br /> ( I Respirator, crce: APR or SC3A <br /> ( I Odie_r, specify A/P c,.:dge• <br /> Satery vest . <br /> %. AnakiDared Biolog-Imi Hazards: [ j Two-way cc=. unic3don <br /> [ I Smites ( I Insects ( I Rodents [ I Poisonous Plants <br /> [ j <br /> CMI e_r/UnImown (specify): PART N <br /> PLAN APPROVAL <br /> 8. Narrative (provide all infar.—z-adi on which could irpac;Health <br /> and Sate^l, e.g., power lines, inre%rir)r of dykes, vermin, erc.): Pian Prepared by. Dare: <br /> T C", <br /> �® Pian Approved by- Dare: <br /> =-:1-108I (2/7/92) <br />