Laserfiche WebLink
SAt`t IOAQU N COUNTY ENNMOPNMEN IAL I~M-kLT�?' DIVISION <br />SITE =A LTHAVD S TY PLAIN <br />?ART I <br />C -M -N RAL SM INFORMATION <br />_. Site Name: <br />Address: <br />Contac, Person: Phone No. <br />Sweeps Ntrmbe-r: <br />Proposed Date of iavestigarion/inmec on: <br />2. Desciprion and brief aasarive of ispec^oa ao:± i . <br />(1 viemr UST rasraladon [ j UAR I-iwes-aigadom <br />(j Tank C:osure is Place (j Tans/Fipe ?Repair <br />( I . ani!c/Dipe Rem -oval, [ I Re-c-mavation <br />C 1 installation of Borzi gs/Monimr'ng Wells <br />Soecidc Site [n-1or=ado= <br />aiL�C No. Tank Capacity: <br />Tank Contents: Tank Age: <br />Cine-'': <br />.- pe of Operation: <br />S. Release H.istor/: <br />pride_^_c_ of leaks/soil conrminarion: C I 7ES [ j NO <br />Doc- :mented Grout dwates contamination: [ 1 7E C I NO <br />Back -ound and des= don or any previous i,.vesdgacon <br />or incde^-ce: <br />5. Poce^_tiai Health and Safer] <br />Pdysical Cance ----s: (chers al t= apniy & desc�.pe) <br />(1 -eat or Cold Stress: o^- (high atabie= m=.) <br />(j Noise Source: <br />C I Ox',rgen pendency: <br />(1 mcavadon: (PaUS, amps ,siippi cave-ins) <br />[ 1 <br />Handling and Transfer of a Hazardous Substance: <br />'fire, expiosions, etc.) <br />(j Connned Soace en=T. Cexpiosions) <br />C I =Heavy e=pme= Cphysicai injury & aauraa resulting <br />iom moving equipment) <br />C 1 Other, spediy <br />7. Aaricipaced Biologics "r-=rds: <br />C I Snakes [ I Insects [ I Rodents [ j Poisonous Plants <br />F 1 ocher/Unknown CsaedM: <br />3. Narrative (provide all inforatadon which could itapac= Health <br />and Saie_ry, e.g., power Lines, inter r/ or dirks, ce-- in, erc.): <br />Z'.23081 (2/7/92) <br />PART U <br />EVALUATION OF POTE'N'TIAL Fs-AZ.ARDS <br />1. Chemicals Hazards <br />[ I Carcnoge :s' <br />C I <br />Corrosives: <br />[ I Dusts: <br />C I plosives <br />C I ? tani ables: <br />C I Inorganic Cases: <br />[ j Memis: <br />[ I Oxidizers: <br />C 1 PC3's: <br />P 4RT 11E <br />Mr-QGIRM ?7RSONAL PROTECTIVE <br />EQUPMEVi <br />i. -Monitoring,=auiprne^sr (note: Monirorug <br />`S— inenrs =List oe Used :or ail opel3IIoris <br />unless aDDropriate rationale or=estTc=ons are <br />provided) . <br />[ I Combustible Gas/Oxygen Meter <br />C I Det--c=r Tubes (Soecr/) <br />C I ?hocoionizar on Desec_or <br />C I Orga=c Vapor Anaiyzer <br />[ 1, Othe.; sperm/- <br />If x onitoem ins==e..rs are hoc .:sed, <br />ratio mie or acdvir/ /area res�:c_'.oas: <br />2. Personal Prrorecri7e Squipmerr <br />i..: ve! of Protection: C Ia C IB C IO [ ID <br />C I Hard 'hat <br />[ I Safe -y basses/;ogees <br />[ I Sleet coed/shank shoes or boors <br />[ I came : emrdant coveralls <br />C I Hearing Pr mchon <br />C I T7vek <br />(j Respirator, crde: A.PR or SC3A <br />A/P car=dge.. <br />CI safety vest <br />C I T Am -way cor inunicmdon <br />PART IV <br />PUAW APPROVAL <br />Plzn prepared by- Dare: <br />P!an Approved by. Date: <br />