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••• • r• • • <br />PART I <br />GENERAL SITE INFORMATION <br />PART II <br />EVALUATION OF POTENTIAL HAZARDS <br />1. Site Name: PAC <br />Address: EAS <br />Contact Person: 2 hone No. <br />Sweeps Number. c2 �, % 7 <br />Proposed Date of investigation/inspection: <br />2. Description and brief narrative of inspection activity: <br />ew UST Installation [ J UAR Investigation <br />[ J Tank Closure in Place [ ] Tank/Pipe Repair <br />Tank/Pipe Removal j J Re -excavation <br />( ] Installation of Borings/Monitoring Wells <br />3. Soecific Site Information: <br />Tank No, / 973 - b / Tank Capacity: <br />Tank Contents: ,' Tank Age: <br />Other: <br />4. Type of Operation: 143 a <br />S. Release History: <br />Evidence of leaks/soil contamination: [ ] YES [ 1 NO <br />Documented Groundwater contamination: [ ] YES [ ] NO <br />Background and description of any previous investigation <br />or incidence S 0, k' <br />7 <br />Potential Health and Safety <br />Physical Concerns: (check all that apply & describe) <br />[) Heat or Cold Stress: OF (high ambient temp.) <br />Noise Source: _ C- <br />[ ] Oxygen Deficiency <br />Excavation: (falls, trips ,slipping, cave-ins) <br />[ ]'Handling and Transfer of a Hazardous Substance: <br />(fire, explosions, etc.) <br />[ ] Confined Space entry: (explosions) <br />Heavy equipment (physical injury & trauma resulting <br />from moving equipment)0,L- <br />[ 1 Other, specify <br />Anticipated Biological Hazards: <br />[ ] Snakes [ J Insects [ J Rodents <br />[ ] Other/Unknown (specify): <br />[ ] Poisonous Plants <br />8. Narrative (provide all information which could impact Health <br />and Safety, e.g., power lines, integrity of dikes, terrain, etc.): <br />EH23081 (2/7/92) <br />1 <br />Chemicals Hazards <br />Carcinogens: _ <br />[ ] Corrosives: <br />[ 1 Dusts: <br />[ ] Explosives: <br />[ ] Flammables: <br />[ J Inorganic Gases: <br />[ J Metals: <br />[ ] <br />Oxidizers: <br />[ J PCB's: <br />PART III <br />•rM.• • y• <br />• �► rx <br />1. Monitoring Equipment: (note: Monitoring <br />instruments must be used for all operations <br />unless appropriate rationale or restrictions are <br />provi d) <br />ombustible Gas/Oxygen Meter <br />[ ] Detector Tubes (Specify) <br />[ J Photoicnization Detector <br />[ ] Organic Vapor Analyzer <br />[ J Other, specify: <br />If monitoring instruments are not used, <br />rationale or activity /area restrictions: <br />2. Personal Protective Equipment <br />Levd of Protection: [ ]A [ JB [ JC [ JD <br />[ Hard hat - <br />Uafery glasses/goggles <br />Steel toed/shank shoes or boots <br />[ J ZIame retardant coveralls <br />[ earing protection <br />[ J Tyvek <br />[ ] Respirator, circle: APR or SCBA <br />cartridge: <br />[ Safety vest <br />[ ] Two-way communication <br />PART IV <br />PLAN APPROVAL <br />Plan Prepared by ate: <br />I <br />PlanApproved by: _Date: <br />