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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES NO[] (b) Is the current certificate of worker's compensation insurance on file? YES V�NO[] (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES VNO[J (d) Has everyone on site,Including cranelbackhoe operator,been certified to work on hazardous waste site in accordance with CCR Title 8? YES NO[] 2. Has a"Site Health&Safety Plan" for this job site been submitted? YES NO[] 3. Has applicant performing removal In the City of Tracy obtained a"Grading and Excavation Permit"? N/A[] YES V NO[] If YES, Permit# 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YES[]NO[W/ 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain)YES VKNO[] ,oc)c-y 7 X-1 UA +Z It 5�- 0o ), 6. If tank residual exists,identify transporting hazardous waste hauler. Name i-y Q F— Hauler Registration# Address O C� Sit i/� City KI j&JL Zip ` O _ Phone#( M'Q ) 9 7 :-k YA Vt 7. Decontamination Procedures: a. Will tank(s)and piping be decontaminated prior to removal? YES[i)/0[] b. Identify contractor performing decontamination: Name b — n�7 r (G pJ r^ Address 1'c ,�d�( �y City4"� 4 i 1 CS Zip Phone Not� � C. Describe method to be used for decontamination: ej 21rr— LAN& F--AnJb :.:`l 'i N (3:p—Scik/tL d. Describe how rinsate material will be stored onsite prior to manifesting offsite: __ S� ��+ l ( �,�►� car SvLE'r�© OL, 7- f3V,'F r-dai--j e. Rinsate Hauler and permitted Treatment.Storage&Disposal Facility: Hauler Name /_ /r7� C i1 t�c:�J Hauler Registration# 02 Address 6, WO �Owl i T-4 A V City cA 14, Zip a/ 4f S/6 C, Phone No.( C -7 V Permitted Disposal Site r�S� ,�,��C C J�• ��Y1 Go �o SO 419 EH 23 046 (Revised 10119198) Page 4