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S�V JO?QLTLN COT-Nr vVV'iRON tyfEN AI. r.AI.i: DIVISION <br /> SITS r�A.LTH AN-D SAFETY PLAN <br /> ?ART II <br /> G AL 5= INTORMATION FVAL=ON OF POTS-N uAL F--A=S <br /> _. Site Na-me: CA, I - 1. Che-icals F-;;— ds <br /> Addzess: ibo�F S�z'T 6Q Cacnogp;S- <br /> Contac?e—'son: Phone No. kQ C=osives: <br /> Sweeps Number. [ I Du=' <br /> Proposed Date ofvesc�t:on/:nsgechon: 0 6Q ,losives: <br /> (4 _z mables' <br /> 2_ Des=-Deo- and brier�*�L^re of inspec-t4on ac^vity: Iaorga is Cases: <br /> [ ] t . <br /> ( 1 New UST irsmlaz:on [ ] UA-P,hues igadon [ I Mss' <br /> ( ] Tank C:osure :-- ?!act [ ] Tan_k/Pipe Repair [ 1 Oo ze-s: <br /> ( ] amk/P'pe Removal <br /> ( ] instalation of 3or_:^gs/Monito=g Wells <br /> ??RT M, <br /> 3. Soer_'_^c Site Trot--fagot=• R`QLIMED P'_E4SONAL PR=ECIIVE <br /> _ark No. <br /> Tank Capacity: EQULn>1rfENT <br /> Tank Conremrs: Lamic Age: <br /> Yl <br /> vLRer: onitOl'^ =gL'1Dnle^C (note: Mo icori g <br /> must be used or ail opens_ors <br /> Type of Coe_-at:on unless aDvmpr'ate zrona:e ores__c_ors are <br /> provide_) <br /> S. Raease �-:scoff [ I Combustible Gu/OX7.e_ Merp' <br /> ride_c_ of leaks/soil coma r=3 I I NO ( ] Dete=or Tabes (Soecif/) <br /> e e ,T, er r C —^ NO [ ] P omioni7-.Lion Decec--or <br /> Ooc��r_d Gtou�dwat� con�ination: , j -� [ I <br /> 3act ound and des"-prion of any previous 'i=7est;9zt:0n [] C=6=c Vapor bra yzer <br /> ( 1 Other, specify <br /> or incidence: <br /> tr monitoryg i^�_:mets are not _sed, <br /> zdonaie or activit;,,/arPe res�:c=ors: <br /> 5. pace- t^e-Itr and Safer, <br /> physic:_[ Gnc_=: (c re f all tsar appiy & desecDe) <br /> or Cold Stress: °' Cnigh amoier-*te=p-) _ <br /> 2. Pe=onal Prole—_ve `qupmear <br /> u:.rc <br /> Noise Soe: 1D <br /> OxygenDefice_cj Level of P-ote=on [ ]A [ ]E [ ]C ( . <br /> [ I amcavado= (_`a?ls, i:^_Ds siiDDin- cave-ins) :ard hat <br /> analin; and T.znsfe: of a hazardous Substance: 64 Safe_ry gia sses/go g es <br /> (Ere, erpiosiors, eta) DQ Steel toed/shank shoes or boors <br /> ( I Confined Soace enz:y: (esniosions) C ::acne retardant cove�!?s <br /> vv _quipae.= cis. m & �t*ma ulting [ ] :-=e=rsng protection] =ea ^ (P� t Jury res <br /> om =owing equiprsent) [ ] Tyvek <br /> [ I Respiraror, crce: APR or S©A <br /> tQ Other, specify Iw1GN1b" ?✓P c.�.d;e: <br /> ( j Safety ver <br /> air ; t Zara G4 Two-way cc=-- :nizmon <br /> 7. �apat_d 3iologic=. 'r_�.s: <br /> [ j Snakes (4 Insects [ ] Rodents [ 1 Poisonous Plants DART IV <br /> [ ] Ot^.e_r/L n clotivn (specify): PT e,N APPROVAL <br /> 8.11.1 (provide all infor._.arion which could mac--?.ea1 'tom oTep�= by ,M -are: 06 <br /> and Safety, e.o., power L^es, inte 'f of d=ices, ter'"3in, e-c-)= di1_�"�� <br /> 'Dat_: 5/�U <br /> a. .Dproved by. <br /> "23081 (2/7/92), <br />