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S _ JO?QLTLN C0U_N Y V RO?v?vLti A =�i i DIVZSiON <br /> SITE E-kTH ?V7 Sr-=1Y <br /> ; PA�TII <br /> t LrvcORMAJ ON rY-ALMACION OF POT=-N UAL 'r1lZ_ JS <br /> :. Site 'Name: ¢ aw - a.4r <br /> Adcess• �' � I_n r•1� (i C=*clogs: <br /> Come Phone yo_'�,33 � _ 3 nrDsives: <br /> Sweeps Nutube .. "° Dus5- <br /> P-coosec Date OF�:rvesd;adon/ispe^_'on: C I _eIOSives: <br /> C] Fiazar,a^ies- <br /> Z Oes^Deoa and bce az=-adve a?shoe^'on ac=vier. [ Ij^o,;a^c Gases: <br /> ( 1 New UST Ins—.�zcon [ ] UA2 Inver on CLYue=s: �1 <br /> ( 1 'ank Cor-=-- i Place (] Taak/Pipe Repair C l Ozi zers: <br /> ( ] Ta^k/Ptoe R—oval ( I �e�=etvteoa CI PG's- <br /> [ ]1inraIladon of 3or=g;/Moaitar ng wells <br /> CSS A- wJ 4Akmera'vf?PR__ <br /> 1L <br /> 3. Soe ^c Site :L'o__ztio= QL�� P `� 1 P� �d <br /> r Yo. Tz✓c G?ac*s =QUiPrs �^ <br /> T—k Contents: Ta=r A;e.• <br /> _. on:COr^g Equ:nrae^_L (note. Mali <br /> Cc: <br /> ts -asz De asec mr s1 0De-zzc= <br /> 'y�C OC vne-=nCL' ,.^less aDDropr_aCC raacna!e or-?S�C=OIS le <br /> wavide^_) <br /> Combustible Cas/Or/UP_ Mete- <br /> of leaks/so1Z conr-•^;^P^pc: C I rj L 1 NO [ ] Dem—or T. (See_%y) <br /> Doe— re_ Crot­dwze_ coa*z--. 4 ( ] `YES C 1 `fO <br /> t ?hotoioc=don De e�Dr <br /> 3accr tmd and dere=pdoa a[ ary previous _ve gadan I <br /> Or;sic Valor?=iryz <br /> [ i Oce, spec s <br /> or _ncceace: <br /> L=catsito,=. s_e=.a are t:oc _sed, <br /> zdaLe or ac_*vin/area reser c=ors: <br /> 5. Pot=^ra -e=1c and Szie=/ <br /> ? ys c_I Coec^^=_:: Cc=e, ail ::at aopiy & descoe) <br /> Q' ai 1—hie' / <br /> ( f -Cat OC Golc Stress: (• Do � <br /> noise SOL:--• onal P-oce_ve ...gt:iDLCC^—t <br /> t , r p�roi P Dcecoc ( ]A C Ia [ IC <br /> ( i Csyg De=ce=c/ (/ <br /> ' nat <br /> s siinping, cave-ins) 1 <br /> azaling and T,�nster ci a 'r?AT <br /> pus Subscac_ a&7 ;a hes/�� es <br /> CE er�iosiors, etc) (i�Siz^I coed/,hznk shoes or boots <br /> ( j Cored Space e=­_T- (emiesions) [ j me retardaae covets <br /> f ' =ezvv egt:ipne_^.r (phym=ll• i#uy& L-z=z resulting ?rotee_cn <br /> ( ] Tyvek <br /> "a= =ov-L'a CL1DL"e"ri <br /> [ ] Respirator, ade: Poo or SC3A <br /> [ A/P cr=dge_- <br /> 7 Other, specry ( ] Suety ver. <br /> Twp=way co�uaicZdon <br /> 7. cpzted 3ioio c_I ^z=rds: <br /> f j Snakzs [ 1 [ se:s [ ] Roden [ I Poisonous Plana PAR:T- iV <br /> [ j Ot^_/UrLlc:o�vn Cs?e=Y)= Pr-,%.N APPROVAL <br /> 8. Na2_ve (provide L zor�adoa which coLc cpac-Hezlt= P!= p-epzred 5y ��� Date: II u1 <br /> and Sated, e.g.. ?ower U-es, inter o[d^ces, te^�ia arc): <br /> ?lL—00roved by. Da-= <br /> -?308i (2/7/921, <br />