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of so <br /> S,Ati .TOA QULN COUNTY. RO?v?ti�:V+� -=A,-_ DIVISION <br /> STT� r�A..i_.TH A-ND SAFE= PLk-N- ± <br /> PART Z ?ART II <br /> CENEiIAL= INFORMA=ON EV-ALUA TON OF POT?v'uAL F-:AZ UMS <br /> _. Site Na--e: �A 1. Ch 'cats -razrds <br /> Address: <br /> Contac Person: Phone No. (j Cot;osives: <br /> Sweeps Number-. [ I Dusts: <br /> P-oposed Date of�vesrigatior./inspe tan: ( ] ' .losives: <br /> amrt a pies: <br /> 2_ Des=--prion and brief n =r ve of irspec=on ac=viry [ j Inorog-anic Cases: <br /> [ 1 New UST I-smilarion [ ] UAR Inves;ig-azion [j metals: <br /> [ 1 Tank CiosPlace ( ] T ank/Pipe Repair [ ] 0e1; ers: <br /> [ I Ta=k/Pipe RP-oval ( ] Re-emcararion [j PC3'5. <br /> ( ] t a-or; of niro=g Wells <br /> 1 P Q.RT IL <br /> 3. Site i *o:_.at=cr.- REQ= PI�RSOKA.L PRT.-=CIZVE <br /> -a.K No. �:ay.K Capacity. EQUIMF- 'l <br /> Tank Canreyts: T at:k Age: <br /> Ct*:e-: _. MonitorT+; =qutp=e--n (none: Monitarm; <br /> p �:� Wut be used :or au opea_o,..s <br /> Type of Cpe_aticn / Lu iess aDDroar?ace.adoaa:e or.es�:c=ons are <br /> provieed� <br /> Release Hstor{. [ I Combus`lle Gas/OxygP_^_ `ifete_r <br /> r,,ride_ce of leeks/soal ccnr'm,narion: [ I -r=S [ ] NO [ ] Dece=or Tubes (Scecif r) <br /> Doc--,-e.--red Grouydwate-r con—minadon: [ j `ES [ I NO [ j Photoio , prion Detector <br /> Background and desc_prion of any Previous cvesrigarion [] Crank Vapor S.naiyzer <br /> or inc:de^_ce: [ ] Otre_; specirr. <br /> If monitaryg ins--=e--= are =or::Se^., <br /> :2no -ale or ac-rvirt/area res�.c_ors: <br /> 5. Pocential realty and Safety <br /> Physical Conc_ (c e�-?f ail :ar apoiy & dese=Be; <br /> I :: _r or Coid St ess: °: (ri,ri amie�*temp.) <br /> oise Source: 2 Personal Procetive Ecuipmer* <br /> ( i OXygen Deuce--c/: Ley,#-1 of P.- re ton: []A [ Ia [ IC :D <br /> [ ] =- varion: (fall, ps ,siiDpina cave-ins) [ .zsd hat <br /> ( I r:andling and .neer of a Hazardous Substance: [ afecy glasses/goggies <br /> e=iosiors, ere) ( 1 St el toed/sh:rnk shoes or boots <br /> [ ] Confined Space erg (espiosions) ( e remrdant coveralls <br /> [ ] Heavy equipment (paysic:3l injury& na=a resulting Hez=g protect-on <br /> om movingequipn:ert) C I Tyvek <br /> ( I Respirator, circle: APR or SC3A <br /> ( 1, odler, speci7: A/P m.":dge• <br /> [ I Safe_y vest <br /> i. Anticipated Biologic_i Hazards: ( I T-Aro-way com--unimmon <br /> [ I Snakes [ ] inse= [ ] Rodents [ I Poisonous Plants <br /> [ I Orher/tinlmown (specify): PART FV <br /> PLAN APPROVAL <br /> 8. Nar-adve (provide aRRl infor-_.arion which could ixpac Health <br /> and Safer/, e.g., power Les, inre-,-�rjr of d%Kes, :e-- , etc): ?!zr Prepared Sy: - Date: <br /> Play:x.Doroved by. Dat__ <br /> =='23081 (2/7/92) <br />