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SAti s Or_QLZV ._;kL z E)I v- -ON[ <br /> ?"R" 'I p SRT Ii <br /> GZ_�AL SME Z7z0RMA=ON EVAL AMON OF POTENMAL F-AZ9Rr5 <br /> _. Sipe Marie; J� f' ?. Ctie_^_tcifs :ages <br /> Address: 1,011 , <br /> Con=Person: P6bme No. <br /> C I Co u nsives: <br /> Sweeps Nua:.be-. ^ , <br /> Praposed Dare or ves o r ort• e�iozi _fir�-? [ I —plosives: <br /> C I R=_I a:,les: <br /> 2. Des='prion and. brie_ �_e='Te of irmecm4o a=`Virp [ I Laa Q ^ic GzseS: <br /> [ 1 New UST r1s-,lIacon [ ] UAR roves=moa ( ] merzfs: <br /> [ ] -ark Cosuzre ,- place ( ] Ta=k/P ip e P.mair [ ] 03� 'i -S: <br /> C ] :'ark/Pine :Le--=czvat;or± <br /> [ ] 'Ir anon or 3or=p/?4far�irar LVe?S <br /> c5v11te GlJi9 (� !a44P_,Y_67(9 ':-J PART. TF <br /> 3. Soe^._�c Sire Emmra: tiom ?W�[t�F� p�SO1�La.L oRCF jC"iTVv <br /> -an_k C;pacirr. F 7UL-DNf_V <br /> arlY T ank Age. <br /> Cr.'er: '. -MOZ korml- =auPme_mr: (mare: :'omicor=; <br /> �, ® �e usec or zii ane_�z-,o s <br /> T; e o[CPe_�hcc /dK� ! =less anar;r:arerioaL z=; <br /> provide:i) <br /> 5. 'Rei-;se z-story: ( j C0=buYzfble Gas/Os*yger_ `Meter <br /> 'lide^C1 0C ley.kS/Solt Cb r! ^-l•TaDe:ear Tubes <br /> Doc-_ima.=r_d Cmumcwaca- c0m=_;mzdQ ': r 1 t:5 [ 1 N© ( ] ohoroiv ;-== on Dere=ar <br /> 3acf o =_d ane dese_aeaz: of any -previous _-7eSri,-aZ0n [] Cr aTsc Vapor SWa:y-z� <br /> or inc'derice: I� k2 � [ 1 Omer, Spe-,- <br /> r�Lr: Ci r=❑nirO� ; ins--�e^;s ars no: see, <br /> P2mo 'e or acuirr/area r .ars: <br /> 6. HealL and Sara.^y i <br /> o�ys-ic=f Cane°°. Cc:--e--, 2L :tzr apvfy & des,=-_ne) <br /> =e,r Or Cafd Jess: ° Cid "....L' bi— <br /> �VOise Source: 2 ae_�Onai ?voce rve .^cs�menr <br /> C i Osfg_= De.^ceacr Level of P'_-ore'^o= []A C IB C IC XD <br /> C l =xcavaeo= ,' ?s, =--ps siinpin,, cave-ins) �•ard aaP <br /> C I =andlin-. an[ Trz=zer or a i-:aza=ous Sub=-rtce: X�Sarerg asses/Qa dies <br /> (Fre, ==iosiors, erc.) [ I Seee_l coed/s"mrk shoes or boors <br /> C i Caged Soace ----=7- (emiosions) C 1 -aae re=&= cove_•zIs <br /> e.vy eauirrIIe=z (gayszcs! uxy 3c cava resulrzn; :earrng 3rorec- cn <br /> =or= ^av+rg -pves <br /> C I Respi mcor, csce: APR or SOA, <br /> [ 1 Ocher, saeci y A/P Ca=--d;e- <br /> ,� J Sare=y ver <br /> /. Azzc#aced 3iolog,c.:.l ^ac'._rdz: A ( I -wa-u+ay cot-_r_T_ icz ior; <br /> I 1 Sr a_kes [ I L^secrs f 1 Rodenrs [ 1 Poisonous Plar_Ls <br /> C 101her/Un-kn0wn (Specify): pART 1V <br /> PLAN APPROVAL <br /> 8. Na-rz> ve (provide &II in-for-anion which cold �aac=�eafr` <br /> and Safe--y, r ;., Powe: L^es, int f of c*_es, Pe<�-aim, etc-):): a!zn preparee by y Dare: <br /> P 0 aAW, _iF <br /> Pf� s.-pvrovec by: Dare��' <br /> _=233081 (2/7/92) <br />