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SA ti JOAQLZN COL?Nt i�' ~ -VRO?��I V -:. HEALTH+ DI VISION <br /> SIT= HEA-LTH AND SA == PLA ti <br /> ?ART i ? T El <br /> Gr. AL SL:E W.FORMA=ON EVALMAMON OF POT N—IIAL F-AZARDS <br /> _. Site Name: 1. Ch cats razards <br /> Address: f,-4"o V t c ( og—: <br /> COIIL3C P_'SOII. Atm- Phone NL o.fio- f� �,[- 3�a Caz�nsives: <br /> Sweeps Nu=be:- ( ] Dusts: <br /> Proposed Date of *vest:;ationJ:nsoec ion: ( ] ---=losives: <br /> 2. Descipdon and brief mar-radve of inspection ac . ( J thorganic eases: <br /> [ ] New UST 1- anion [] UAR Invesdgation X j Memis: <br /> ( I Cosu-e =: Place [ I Tank/Pipe Repair ( I Oadizess: <br /> CvrTa:.k/Pipe Rte.=oval [I Re--=cavat:on []PC3,s: <br /> ( ] Im-sallamion or Bor�ngs/Moniroring Wells <br /> P A.R T <br /> 3. Soec?. c Site t=fo^atior: REQTj= PF S7NNr+L PT�L=CTIVr_ <br /> ankNo.3�1 1144-®Co :'a: +c =pacry: r�® � EQtTL�L tT <br /> Tank Conrenrs: ,t Ta. k A;e: a m . <br /> 0�-ie_•- <br /> I. Moairor-- =quipmenn (note: Moniroeine- <br /> sr- �crs : Lsr be used :or all oper-a-tions <br /> 4. <br /> Type of Ope_--adcII sv5 or- raless mrirorim rarioIIaie or.es _ors are <br /> provide d� <br /> 3. ease I- sror/: ( ] Combusnole Gus/OzyT;e-r- Mere-- <br /> ,rideace of leaks/soil cnr* i-Tion: ( j -r=S [ ] NO [ I Deter Tubes (See:iy) <br /> Doc,menred Gro=-dwate-- conmmination: ( I `:"':S ( ] NO Vwy- [ ; Phoroion;7--don Detecor <br /> 3ac'_tg=ound and desc-'pt:on of any previous inves ippon (I Organic Vapor A aiyze- <br /> or incidence: ( I Other, specify: <br /> l! —=aniror:yg i^..SL:.'z=e rs a-re zot::sed, <br /> rar:or-ie or activity/area- res-:edors: <br /> 5. Pocential ^eaitr ar+d Saber,/ <br /> Plzysic:.! Coact---s: (cL-e--:- all ;bar appiy & descDe) <br /> ( ] Hear or Coid Stress: °F ('high ambi—temp.) <br /> [,,�oise Source: I Personal Prote--ve :auipme--- <br /> ( ] Oxj►gen Denee=c•/: T.,eve of Pore tom: [IA [ IR ( IC .H� <br /> ( I =-cavadon: (res, -"--os ,siippino cave-ins) Hard hat <br /> [�:andlin; and Tz-ansrer of a Hazardous Substance: �4fa&-y asses/gog,es <br /> (l=re, espiosions, e_c.) -Ceer toed/shack shoes or boots <br /> ( ] Conlzned Space entry: (expiosions) ( ] ::ane reardanr cover-alis <br /> [vj envy eauipme= (physical injury& t:a=a resulting [ jHearing prnrec°=on <br /> "ora moving _C -4==r) (j Tyvec <br /> [ I Respiruor, circle: APIR or SC3A <br /> [ ] Other, spemery A/P m,.—=d;e <br /> ( I Safey vest <br /> i. n-dr-pared Bioiog,-c:d Ha—zards: ( I Two-way communimtion <br /> ( j Snakes ( I Lnsecrs [ I Rodents [ I Poisonous Plants <br /> ( I OL-er/Unkriown (specify): PART iV <br /> PLAN APPROVAL <br /> 8. Na-r-adve (provide all infor�adon which could iMac Heaith l f t--az, <br /> f <br /> �4 ov <br /> and Safety, e.g., power l--es, inre—,-'7jjr of d_Kes, :e-- mn, em.): Plan ?rer�ared by Dater <br /> ?!an.Approved by. Date: <br /> -73081 (2r/92) <br />