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S,� V IOC QL'N,COLNi`IVO�Ti+�L. �:�al,� D>ti��iON <br />SITS 'HEAL7H .A.LNl D SAI <br />?ART i <br />?ART B <br />G"r✓Vf 3I. 1_r. LN-FCR�ML A :,ON <br />-zVAL CN OF PCT2N%AL HAZARDS <br />_. Site Marne: ezl�VAFR+ <br />1- C:Amicafs Hiazards <br />Address: '2i CY / <br />Ca'rGioge_ : <br />Conrac. Person: ?hone No. <br />(j Carrosives: <br />Sweeos Nurnbe_: , 3 L/ <br />Proposed Date of =7est:gaaon/inspec: on: s" '"lL <br />[ 1 Ousts: <br />( j =--�fosives: <br />��ammanjPs: <br />? Cesepdon and brief narrative of spec=on ac=viry: <br />C I [norganic Gases: <br />[ 1 New UST i_.sIat:on [ j UAA invesidgatomLietafs: <br />[ j 7an..k C:osure � : Macs ( j Tank/Pipe Repair <br />[ I Caaiz_rs: <br />ipe .Removal (j Re-e-.cavatoa <br />�iztzmon <br />[ 1 ?C3,s: <br />of 3orygs/Monimryg Wefts <br />? aRT <br />3. Sce._'cc Site [ata arida: <br />RCQL-= ?,—pqS,-AAL ?ROTzc.-LIVE <br />'_nk No. 1— Tank Caparty: flr,kL'S) 11'C�� <br />�S�C�> EQUIPME:Vi <br />"i^'C Conr'e-ars: Z w L2 l ank <br />Man_rorng ?quipraenc (none: Mon_roHn, <br />m.-s==Pits =us- 7e used or aL ape_rar-ons <br />S!�1 ` <br />77ve of GperaLCn: (}� 7 oxi <br />1r'ess m-croDr are _t_oaafe or-asz:--c=ons are <br />provided) <br />:. .Release =_storl <br />t4-.�"orabusa2bfe Gas/Osney Mere_- <br />3,nde_^_ce of leaks/sail cons—inaron,_ [ I '--5 C I NO <br />[ I Cete=or Tubes ;Seer.^l) <br />Doc -=,^red Gtpuadwate_r contazniradon: f 1 72S C 1 NO <br />(I ?�otoio i -n on Gere -or <br />3ack-ound and ces=' ran or aa7 ?revious � :vesmgar-on <br />(I Cr;ar_ic Vapor Ssaiyzer <br />or 'nc'_dence: <br />C I Crier, spec-/: <br />:f :�.onitOrmg s_T.S� 'r'etirs are 7-Oc _sed, <br />==Chafe or ac".?virr /area :es�=-C_Ons: <br />C. ?ocentai -erfL'I and Safe^l <br />?hysicsl Cance—: (cye�-'r ail War appfq 3c desc�e) <br />[ ear or Coid Suss: _ a* /,P!% 07 C1ig2 bie= =D.)oise <br />Source: C �1LT-- <br />Z Pe,;oraf ?=cer7e lcuipmenrr <br />C I C=lgP.: De-ffre=egl: <br />Level' of ?rote ton: C lA C IB � <br />k=cavadon.: (falls, DS Ziippin- cave-ins) <br />L` /��Q � <br />(j Rangling and Tz3ns:e_ or a razardous Subs=ance.- <br />C`FSare--7 asses/gogtes <br />(Ere, explosions, ecc.) <br />�Sie-' coed/shm-k woes or boors <br />[ j Confined Soace exn7: (espiosions) <br />( j :'same :e=dam covamils <br />I t --r (pdymc:3i =I '3c -"au --a resuimag <br />cLI cavy e^.USD!IIJ <br />-",--Orn <br />e3I'�ng ?rate—on <br />Tyve_k <br />loving _yuiorne^.t) <br />N -Respirator, crce: or SGA <br />C I Gbe:, sperrry <br />A/P c -.-r,—. ge- - -A) - <br />( 1 Safety ves= <br />7. .inridpaced 3ioiog:cai C m--rds: <br />(I '. Wo -way cDZL`.^LT.SZ '=or- <br />[ j Snakes C I irsec- fO.Roden= [ I Poisonous Plants <br />(j 0Lher/lirrimoi%m (spe y): <br />?ART V <br />PLAN APPROVAL <br />3. varradve (provide all iafbrr.+acon waic:i could :amac: Heal:: <br />and Safe^l, e.,., ?ower Lyes, [nregi-# or d-kes, _e_:�in, :!Cc-': <br />?!=?repared by-. 1!5-r Gare: <br />?rte acoraved by: Darer� <br />-'2308 i (2/7/92) <br />