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Approved RCN-5103-2 REPORT NUMBER RNO U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-5139 Rev. 6-04 SOUND LEVEL SURVEY REPORT SOUND LEVEL METER CALIBRATED MFG. INITIAL SURVEY MODEL TYPE OTHER INDOOR SN OUTDOOR Wind Screens Will Be Used On All Measurements Indoors and Outdoors ILLUSTRATE PAGE 2 WITH DESCRIPTION OF AREA WHERE NOISE SURVEY IS CONDUCTED PLUGS IDENTIFY SPECIFIC WORK LOCATION AND NOISE SOURCE DBA READING DBC FULL NAME RATE OR JOB TITLE AND SSN OF EXPOSED PERSONNEL TWA MUFFS NONE COMMENTS UNIT NAME TIME DATE NAME AND TITLE OF PERSON TAKING SURVEY LOCATION OPFAC NO. PREVIOUS EDITIONS ARE OBSOLETE COPY TO G-KSE-3 COPY FOR FILES LIST OF NAMES TO MEDICAL DEPARTMENT Reset P age 2 of CG-5139 Rev* 6-04 DIAGRAM OF AREA AND OPERATIONS Instructions Include a diagram of the operation or work area indicate the primary noise source by a circled A and secondary noise sources by circled B etc* workers shall be identified by circled numbers indicating relative position s to the noise source which should coordinate with names of exposed workers on page 1 of this form* One number may appear on the diagram several times if the employee moves to two or more positions having differing sound levels. Identify type of machinery model number manufacturer dimensions kind of deck overhead and bulkhead surfaces. Has area previously been designated and labeled noise hazardous Retain one file copy for 20 years mail one copy to G-CSP-4. PREVIOUS EDITIONS ARE OBSOLETE COPY TO G-KSE-3 COPY FOR FILES LIST OF NAMES TO MEDICAL DEPARTMENT Reset P age 2 of CG-5139 Rev* 6-04 DIAGRAM OF AREA AND OPERATIONS Instructions Include a diagram of the operation or work area indicate the primary noise source by a circled A and secondary noise sources by circled B etc* workers shall be identified by circled numbers indicating relative position s to the noise source which should coordinate with names of exposed workers on page 1 of this form* One number may appear on the diagram several times if the employee moves to two or more positions having differing sound levels. Identify type of machinery model number manufacturer dimensions kind of deck overhead and bulkhead surfaces. Identify type of machinery model number manufacturer dimensions kind of deck overhead and bulkhead surfaces. Has area previously been designated and labeled noise hazardous Retain one file copy for 20 years mail one copy to G-CSP-4. PREVIOUS EDITIONS ARE OBSOLETE COPY TO G-KSE-3 COPY FOR FILES LIST OF NAMES TO MEDICAL DEPARTMENT Reset P age 2 of CG-5139 Rev* 6-04 DIAGRAM OF AREA AND OPERATIONS Instructions Include a diagram of the operation or work area indicate the primary noise source by a circled A and secondary noise sources by circled B etc* workers shall be identified by circled numbers indicating relative position s to the noise source which should coordinate with names of exposed workers on page 1 of this form* One number may appear on the diagram several times if the employee moves to two or more positions having differing sound levels. Identify type of machinery model number manufacturer dimensions kind of deck overhead and bulkhead surfaces. Has area previously been designated and labeled noise hazardous Retain one file copy for 20 years mail one copy to G-CSP-4.

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