Laserfiche WebLink
S A ti :OAQLZN C0U ice'' EYV1 RO_t-NL� -A:-, `. DIVZSIL 0N <br /> S== PEA LITH A_ti-D SA:�rTY PLS N+ <br /> ?AR: I PART 71 <br /> INFORM lON LV_ALU-A=ON OF POrN+TiAL HAZARDS <br /> _. Site name: �� i_ ,e�'-iC- ry�-ar <br /> Address: , C�rcnogers: _ rCuz^lr� <br /> Contac?°_-son: r 2/ c Phone No_ ', _ [I Corrosives: <br /> Sweeps Vuaber-. �2.�b;aas�, [ I Du=: <br /> Proposed Date of vesri zrion/�inspe ton: [ I =_ plosives: <br /> pies: � <br /> 2. Desciprion and bier=—_=47e of inspecrion ac_MLY [ j Inorganic Gases: <br /> [ 1 New US i^ anon [ ] UAR Invesrig=on (j Metals: <br /> [ 1 TankGose ;: Place [ ] Tank/°pe Repair [ I Oaesze_•s: <br /> ( j Tark/Pipe R�=ovai ( j Re-��c iron [] PC3's: <br /> [ ];zs Il ation of 13ores/�M_o"giro g Wes <br /> �. Soe^—dire Lf0=anon: REQUIEFFD P-RSONAL PRO==C=_- <br /> -=nk No. -z=lk Capacry. BQUL=I <br /> -ank C0=e_-_rs: "^c A;e: <br /> } monitor^P =quipaera (norz: Mo irorr'_o <br /> =fist oe usec :or 21: oDLczons <br /> -rPe of Ope_-arient � Uk /,v (,c'irfunless aDpropr'ate zt ona:e or.es�cors are <br /> provided <br /> Q eiease r=srorf [jl'Cambusnole Gas/Gr/-e_ Me:e_- <br /> ride_ce of leaks/soil conr`r,; 'or: 'zs [ ] NO I j De:ecor Tubes (Sge��) <br /> r,�-__ <br /> Doc•*zmred Grou^dware_r con*-.,rntrario= [ j vS /&TNO [ i ?hotoio tion Decec:or <br /> 3ac.1c;-01md 2--C/,aescarien of any previous =esmaarion _ yj�Cr-5,=c Vanor Analyzer <br /> or inc:de^_ce �O.� lay �-� /6L��, rl(,67a /36! /[ ] Ct_,er, specify: <br /> are r;or _sea, <br /> ra^o -aie or ac-- ry/are'- reser:c_ors: <br /> 5. Poce_nnai :.ea_it+ and Safer/ <br /> ?bysicai Conc_^s: Cc:--e--;., ail rvar anoiy & descne; <br /> or Coid Sress: °: (:ice arabien:re rp_) <br /> - <br /> me <br /> [ j Source-Noise Soce: Z Pe_.onal ?rore r ... <br /> ve qui. 1D <br /> [ i C--Igen Dence_^_cj: Le I or-P-ore mon: [ ]A ( ]B [ <br /> ] � n <br /> CavaoL': (rte, 'JS ,SL1Dn1L'a, Q4e-CIIS) L <br /> "�analin� and T.-anszer of a r_a=raous Subs.3nce: / 7 giames/goQaies <br /> "fire, spiosiors, erc.) , Sceel toed/shz-ok shoes or boors <br /> ( ] Coailned Space e: (expiosions) ( I =lame remrdanr coverzlls <br /> f ] -eavy equin=e= (pi m—I injury& =2=a resuriag [ I Hearing prorec-roa <br /> ?0a Ovin$ "Dme�r) [ J L7vek <br /> _Respiraror, crcle: AP or SCBA <br /> ( ] Orher, spec_*y A/D c....=:dae- <br /> ( I Safety vest <br /> 7. Ar-ricipared Bioiogic:: :?aLrds: [ ] Two-way corm-unimrion <br /> f ] Snakes [ j C I Rodents ] Poisonous Plants <br /> [ J Or er/rumi tolvn (specify): /_,In L►''OLU?'L� PART iV <br /> PIAN APPROVAL8. Na_*-arive (provide alul information which coud ir : H <br /> aacealtL <br /> and Safer/, e.g., power L^_es, inre;-sy or G:.res, :e_—air, erc_): PIa ?repared b r mate: <br /> ?rte Approved by. t..' Darer <br /> -?308: (2/7/92) <br />