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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES W NO f j <br /> (b) Is the current certificate of worker's compensation insurance on file? YES 61 -NO[] <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES[ NO[] <br /> (d) Has everyone on site,including cranefbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 8? YES NO[1 <br /> 2. Has a"Site Health&Safety Plan" for this Job site been submitted? YES H NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIAX YES ' NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA(]YES[]NOX <br /> 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain)YES[] NO[ <br /> 6. If tank residual exists,identify transporting hazardous waste hauler. <br /> Name �lf'16l t W-r V�L G Y C)I (- Hauler Registration# �7 <br /> Address i ,0. 1�0 X 3 q0 City Jbft,14L Zip 9513 <br /> Jr <br /> Phone#( <6-M ) '13d, --4b 4 <br /> 7. Decontamination Procedures: <br /> a. will tank(s)and piping be decontaminated prior to removal? YES[d NO[] <br /> b- Identify contractor performing decontamination: <br /> Name SEMCO <br /> Address 1217 South 7th Street City Modesto 71p 95351 <br /> Phone No4 209 ) 524-9653 <br /> e. Describe method to be used for decontamination: <br /> The tanks &_ piping will be triple rinsed at 180° using a low volume, <br /> high pressure washer. The first rinse will include the use of a bio- <br /> degradable detergent. The two final rinses will be clean water. <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> The rinsate material will be stored on site in DOT 55 gallon drums <br /> with <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name F}/YJ C�I C41y "Ll-L`� I Hauler Registration# 3 T <br /> Address T• 8 , Zb 3 D City :b&-H= Zip 5 3 5 <br /> Phone No.( Typ ) 3 — </b qS <br /> Permitted Disposal Site J fJ nu S'f7Z t/.]1r 5 6,2VI tZ 0 i L l h�c . <br /> EH 23 046 (Revised 10119198) Page 4 <br />