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S�ti IO?t2L COTJTMf -tZ0?V:L ► L Ari^ DI ICKON <br /> STI= -?.LTH A_`7D SA- =t 2L v <br /> ?ART I ?ART IF <br /> ��Z s. ' amFOPL rlA=GN zVAIZA=CN CF PO"1ENTlAL F-47-ARDS <br /> _. Site Name: �! L Ca 'c3is :az��-cs <br /> Address: r C=�og�=s- <br /> Contac:P_ an:ljgL h& M ?hone Na. C I Carr=ives: <br /> Sweeps Nuybe_*: C I <br /> Proposed Cate of mve4cgat:orJ ec=oa: ( r.ies:ves: <br /> 2. Des=*D on and brie:,� a of�=e=*on acyl: C j Enorganic Cases: <br /> [ I New GST Inset aeon (j UAR invesdgadom <br /> 51 ax C_.;^ <br /> ar_,:vTipe Rerovai <br /> ( 1 iasc 17ar'.om or 3or.^;s/Monimr=g Weis <br /> ?ART <br /> 3. Scud Sir_ L-ZQC=at'c=: RdQL= PC_-lSCW_L?QC'r'C'iIs1E <br /> -amk Vo.m7 -O l-00 an Capa�^l _ O =QL ?iii iT <br /> Canr�rrs• d ^ -mY Age. <br /> Chan =quipzre=a C=oca: Vc=,,: arbz; <br /> _e^. Je sed or =i.� ope:-a�ors <br /> Type ac Cue-rt cn: W �*.Mess r:pr. - .conaie or cons are <br /> ��ease :stor pro <br /> t <br /> Cbt_s,,:cle Czs/C .= fifer=� <br /> =ridence of leaks/sail co -en: [ , '.-S (I NO [ ; Ce*=r Tubes CSeec.7: ) <br /> Doc e=r_d Grou-charm cn=uni .anon: C NO 1 ?�'QLaIaL'T�t OII Der <br /> 3ac'_:,ground and : tion or=7?rmous :_esmgat on [j Cr;anic Impar? a qz <br /> or incidence: y,��.,, [ j Com, spec�:-r. <br /> Efj.eaitor. g ir�,�-moo.*+*e _a— =er.sed, <br /> mdcmaie or ac vx7/area <br /> Ph, ri Czrlc?-^-s: Cc�zeizk ad War a=i7& des= e) <br /> _c or Caid Sys: ll Cm= aat:biear <br /> [ Noise Source_- Z ?� amai ?^otee =.^u*pse�r <br /> C I Cx7gen Ceffda=l: r or?rorer = (IA C IB C IC <br /> [ I ;caval on: CFka, vis ,Si=mT cve-jail) - mar <br /> C I Handling and-.ansfer of a F-izmrdous Sabsmnc_.- U7 y 'T =es/;og es <br /> ` zee exmicslons, em) ( Sre' coed/yi! ._k.saioes or boats <br /> r I rgm,named Soace m=7-. (expiosions) C! e m•• =-r coeds <br /> svy e;tu ame::r (papscsi =Jm7 3c mmi=,- ( ,gi g-r=oom <br /> =oim sov+ng uiaae::r) C I Tpvek <br /> C IRespirator, e_ce: APR. or S(MA.C I Safer vert <br /> 7. Ar z spaced 3ioialk-..f raz~rds. (I *0-wa7 car^*^t•^:cion <br /> [ 1 Snakes C I Ir-sec= [ I Radars [ j Poisonous ?!amts <br /> ( I (Or_^e-/Gn.=owm Csspe_ry): Pad_ N <br /> PLA24 APPROVAL <br /> 3. :Naar awe (provide a-? i�*or-�acoa wick: cot:d upas HeaLt <br /> and Saie_^j, , ?Ower Lr es, integr#of di.km, :a=zim, rrc.): ?!a: ?:`Pared �y t,are: ✓v► <br /> -j / <br /> ?ta mvroved by. ]are:7 22 <br />