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M Ar <br />1X I - 0963krjklicolz <br />• i " <br />PART I <br />PART U <br />GENERAL SITE R-WORMATION <br />EVALUATION OF POTENTLkL HAZARDS <br />1. Site Name:EA-A-MV,'> Z 4' ! <br />1. Chemicals Hazards <br />A <br />Address: / <br />Contact Person: 6/)&XA70,4 Phone No. <br />[ l Carcinogens: <br />[ ] Corrosives: <br />Sweeps Number. <br />[ I Dusts: <br />Proposed Date of investigation/" n: <br />[ ] osives: <br />Flammables• <br />2. Description and brief narrative of irmpection activity: <br />[ ] Inorganic Gases: <br />[ I New UST Installation [ ] UAR Investigation <br />[ ] Metals: <br />[ I Tank Closure in Place [ ] Tank/Pipe Repair <br />[ ] Oxidizers: <br />;VTank/Pipe Removal [ I Re -excavation <br />[ ] PCB's: <br />] Installation of Borings/Monitoring Wells <br />PART III <br />3. Specific Site info tion;. /� <br />Tank No. °� 9 Capacity: <br />REQUIRED PERSONAL PROTECTIVE <br />EQUIPMENT <br />c�' ank <br />Tank Contents: Gi/. C-7) Tank <br />Other. . ®� Z 1 <br />1. Monitoring Equipment: (note: Monitoring <br />4. Type of Operation: ✓ (ems / / <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provided) <br />S. Release History: <br />[ I Combustible Gas/Oxygen Meter <br />Evidence of leaks/soil contamination: [ ] YES [ ] NO <br />[ ] Detector Tubes (Specify) <br />Documented Groundwater con 'on: [ ] YES []NOP <br />[ ] ionization Detector <br />Background and description of any previous investigation <br />'c Vapor Analyzer <br />or incidence: <br />[ I mer, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />6. Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[ ] Heat or Cold Stress: OF Ngh ambient temp.) <br />[ I Noise Source: <br />2. PeroProtective Equipment <br />[ I en Deficiency: <br />of Protection: [ IA [ IB [ IC [ ID <br />avation: (falls, trips ,slipping, cave -vas) <br />UKard hat <br />[ I Handling and Transfer of a Hazardous Substance: <br />Safety glasses/goggles <br />(fire, explosions, etc.) <br />[ I Steel toed/shank shoes or boots <br />[ ]ed Space entry. (explosions) <br />injury & <br />[ ] Flame retardant coveralls <br />[ ] Hearing <br />[ envy equipment (physical trauma resulting <br />protection <br />from moving equipment) <br />[ 7 •eek <br />[ ] Respirator, circle: APR or SCBA <br />[ ] other, specify <br />A/P cartLidge: <br />[ J Safety vest <br />7. Anticipated Biological H= <br />=erits <br />Two-way communication <br />[ ] Snakes [ I Insects [ ] Poisonous PIants <br />[ I Other/Unknown (specify): <br />PART IV <br />8. Narrative (provide all information which could impact Health <br />PLAN APPROVAL <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />Plan Prepared by: Da r <br />Plan Approved by: _ Date�� <br />EH23081 (2/7/92) <br />