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SAINT IOAQUIN COL-NTY-v�RO?�-ME: .�I.1 �,i-'i'FI D7TiSiON <br />STI r- FF—',.LTH. ND S TY PLAN <br />PART I <br />GaNERAL sm. INFOR.'vl =ON <br />i. Site Name: <br />address: <br />Contac-- Person: Phone No. <br />Sweeps Number: <br />P-oposed Date of nveszigadon/hssaee-= <br />2. Despdon had brie= madve ofsoecdaa activity: <br />(1 New UST moa C I UAR. ieszgatiog <br />C1 Tank C:osure in Place ( I Tank/Pipe Repair <br />C1 T as-V'P:Pe Re+ovai ( I Rzlaxcm oa <br />[] tasmiladon of 3or ngs/Monimring Wells <br />;. Soec=c Site L-Zor=adon: <br />Tank oto. Tank Capacity: <br />Tank Contents: Tank Age• <br />Crher: <br />Type of Cpe_t-:don: <br />S. Reiease H.istorf <br />,7idence of leaks/sail canmlll narion: [ I '--, [ I NO <br />Doc-* T ented Groundwater cons ir.a on: ( I ?G. S ( 1 -T0 <br />Back round and desc_'pdon or any previous s7esd9=On <br />or incidence: <br />5. Pocendai :eaidi and Safe -7 <br />physical Conch.^...s: Cc+eck Z dar appiy & desc.De) <br />[ 1 Heat or Coid Stress: °^- Ctaigii ambiens te=.) <br />C I Noise Source. <br />C I Ox=ygen Dedcie=7: <br />C 1 cavadon: Cfa ls, asps ,slipping, cave-ins) <br />C I Handling and Transfer of a Hazardous Sub=mce.- <br />(fire, expiosions, etc.) <br />( I Confined Soace ent yy: Cesgiosions) <br />[ It-eavy equipffiMr (jaIIySIC3i injury 3c tramna resulting <br />offi moving egtnp==r) <br />[ I Other, spe=7 <br />7. anticipated 3iologic-..F "ca=rds: <br />[ l Snakes ( I insects ( 1 Rodents <br />[ I Orhe-/Uniatown (specify): <br />[ I Poisonous Pians <br />I .maraave (provide ail information which couid atpac Health <br />and SafeRl, e.g., ooww lines, inte%!:_rj of d?ces, :e=zin, erc.): <br />E -:-:—)108i (2/7/92) <br />PART II <br />EVAI,UATTON OF po-rL i17AL Y AZARBS <br />1. Chemicais Hazards <br />C I Carcnogens: <br />C I corrosives: <br />C I Dusts: <br />C I Explosives: <br />C 1 rsa�oles. <br />C I inorganic Cases: <br />C I Mem: <br />[ I O�dize*s: <br />C I PQ's. <br />?ART 01 <br />,REQUIIUD PI-7RSOMAL PROTECTIVE <br />EQUIPmaT <br />Moaitor-ng �auipramr: (note: Ltonitarm0 <br />irs==e..ts ,=us-oe used cr ail ope*adons <br />oniess appropriate mdonaie or _esv ci ons are <br />orovided) <br />L I Comous-Ne Cas/oxnen Nfeter <br />I I Dere—.-or Tubes (Specify) <br />[ I Photoionizadoa Decor <br />C I Organic Vapor gnai7 <br />C I (3ff, spec�Py: <br />[f atonimrjmg it�=encs are hoc ::sed, <br />rationale or acdv 7 /area -waic=ons: <br />2. Personal Protect+ ET#=en <br />Level of P.otecd on: ( IA C IB C IC C ID <br />CI'Hard har <br />[ I Safety giasses/goees <br />(1 Steei coed/sdaak shoes or boats <br />C I came retardant coves <br />[ I '-:eating Protecton <br />C I T7vek <br />C I Respirator, circle: APR or SC3A <br />A/P c2,- midge: <br />C I Safety vest <br />C I T mo-wzy com^unicradoa <br />PART IV <br />PIAN APPROVAL <br />Plan prepared by: Dace: <br />Plait kDproved by: Date: <br />