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3 <br /> A. GENERAL INFORMATION <br /> Client: /7F/I rn�f ��;rrG (.[_ Delta Project Number.[)^ _ f <br /> Site Name: Client Claim/P.O. Number, -- <br /> Site Address: _ CYL�r; Site Owner: <br /> Project Manager: <br /> Pian Prepared by: C .- Date: <br /> Approved by: -Date: <br /> Revised by: —Date: <br /> Revisio <br /> ate- <br /> Revision Approved by: Date: <br /> Proposed Date of Investigation: Date: <br /> Objectives: '.'// 3 sv;% 6o��nr.5 "19, rnRX��l7�/rr� <br /> Summary of Potential Hazards: <br /> [ ] Chemicals (List: AJoAx ,A J Noise K Heavy machinery <br /> [ ] Ladder/scaffold [ ] Biological ; <br /> [ ] Electrical ( ] Radiation <br /> [ ] Confined spaces <br /> [ ] Other (Describe: <br /> Safety Equipment Required: <br /> bc] Hard hat [ ] Gloves <br /> }. Safety shoes [ ] Protective clothing <br /> { ] Safety glasses [ ] Hearing protection <br /> ( ] Respirator (Describe: <br /> [ ] Other (Describe: <br /> Monitoring Equipment Required: <br /> HFhNLJ/OVA <br /> 02/Expiosimeter <br /> ( ] Detector tubes (List: <br /> [ ] Other (Describe: <br /> SF-904MR/Page 2 <br />