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SAt`i .TOAQUL T COTJ= M'N-VMO?--if EN- 7.A i, PMAL 7zI DMSiON <br />ST> E =ALTH AND S TY PLk -N <br />PART r <br />GENERAL SITE INFORMA'IION <br />_. Site Name: 4— <br />address: <br />Contac: Person: Phone No. <br />Sweeps Number: <br />Proposed Date of investiganon/fnspection: <br />2. Desciption and 'brie: aasra&e or inspection ac:± i . <br />( I New UST installation (j UAR tavestigZdQn <br />C I T an_k C=on= it Place (j Tank/Pipe Repair <br />C I T ank/Plpe Re-novai (j Re-a=vation <br />C I Installation of 3or ,-V/Monitorimg Wells <br />3. Soe=—c Site rl-Formation: <br />"ank No. <br />-am: Contents: <br />T anti Capacity <br />Tanis Age- <br />Ct:*se*: <br />?. Tyne of Operation: <br />j. <br />7 <br />Reiease�SLorj <br />vidence of leaks/so$ conmrcti anon: C j-'.'c_.S ( I NO <br />Doc -=eared Groundwater conmramar on: C I`:_� ( I NO <br />Bac::; -ound and (iesa--vld a of any previous invesaggazon <br />or incidence: <br />Pocenrai Health and Safer/ <br />Nzysicai Conc_^-s: (cYeck as chat m iy & desc.Ae) <br />(j ; .ear or Coid Sr, --ss: oi. (high ambient gyp_) <br />( I Noise Source.- <br />( I Oxygen Deticmcy: <br />C EXCaVadO= (fails, MMS ,3i!ppiMI cave-ins) <br />C I <br />Handling and Transfer of a Hazardous Substance: <br />(lire, ea'viosions, etc) <br />( I Cottoned Soace end: (expiosions) <br />C I Heavy eci ipr ene (pa7mcai injury & =mna resuinng <br />from moving ecuipmear) <br />( I Other, specify <br />Anticipated Bioiogicsi Hazards: <br />( I Snakes ( I mr secs ( I Rodencs <br />C I Cthe_:/Unkmowa (specify): <br />C I Poisonous Plants <br />PART 11 <br />EVAL=CN OF POTMiLMAL Is. ,ZARDS <br />1. Che=icaisr'azards <br />C I Carcinogens: <br />C I CaLrosives: <br />C I ��- <br />(I Expiosivees: <br />C I ?armmabies- <br />C I Inorganic Cases: <br />C I Mem: <br />C 10 'dizers: <br />( I PC3's: <br />?ART M <br />REQTj= PERSONAL MB.OTECZZVE <br />EQULPNO-q ' <br />1. -Monitoring E quinme^L: (note: Mo ** or=g <br />:sem=—enrs mz:s: be used :or Z ape amons <br />=,mIess anvroprare -an omie or_es�:actions are <br />?rovide-d) <br />( I Combustible Cas/Cx7gr * Mere_r <br />C I Deter Tubes (Specify) <br />( I PFotoioni7m-tion Derec_or <br />C I Crg=*c Vapor?.naiyzer <br />C I Offer, speciej: <br />If =oniror�ag ins=. mems are sot ::sed(, <br />mdonaie or actvirr /area :esuactions: <br />2. Personal ?rocec&e cc:ruiomear <br />T.-; ve? of Procewon: C IA C IB C IC C ID <br />(I <br />Hard Bat <br />C I <br />Safer -7 ;asses/goggies <br />[ I Steej coed/shank shoes or boors <br />C 1 = =ame retardant coveralls <br />[ j 'Hearing protect on <br />C I Tyoek <br />(I Respirator, crcce: APR or SC3A <br />A/P ca^dge: <br />C I Safety vest <br />C I Two=.Nay commi:nication <br />PART 'IV <br />PT -A -N APPROVAL <br />3. Narrative (provide al? information which could i apac: Heait-6 <br />and Sate^/, e.g., ?ower Imes, inter/ of d:?ces, :e=aid, esti.): ?ia : Prepared by. Dare: <br />Pian Approved br.. Dare: <br />=' 1081 (2/7/92) <br />