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REGEIVED <br /> 1. (a) Is the current certificate of workers compensation insurance on file? MAR 10 2016 YES NO[) <br /> (b) Does the contractor possess a"Hazardous Substance Removal Cerci I p��;'�^^�� II►���I ww''TY NO[] <br /> (c) Has everyone on site, including crane/backhoe operator, been certifie=IofVNMEN I, �_ <br /> hazardous waste sites in accordance with CCR Title 8? +,��!Ts r nr:P0j0Tnn=NVrE* NO[] <br /> 2. Has a"Site Health &Safety Plan"for this job site been submitted? YEK NO[] <br /> 3. Has app ant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/AX YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAXYES[] NO[j <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES[] N <br /> 6. If tank residual exists, identify transporting/hazardous waste hauler: <br /> Name Llf Hauler Registration# 3 <br /> Address fo- &D2 3 City OLC-Z41/ Zip -7.;,--3 <br /> Phone#(Z�'I ) 46 7'-y <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YESX NO[] <br /> b. Identify contractor performing decontamination: // �` <br /> Name J/n? 71-1ali <br /> Address_B Oo -35 7 City C/inv Zip 22L <br /> Phone No.( ;�a ?_, -3 6 g-CK"I <br /> C. Describe method to be used for d ontamination: <br /> 7 z`1,, ,6 O.d <br /> d. D scribe how rinsate material will be%ored onsite prior to anifesting offsite: <br /> s,o2�,� / 19 �',Zo�/L. /S`iyZ�y/ j D,zd�7S <br /> n)SJr1 <br /> e. Rinsate Hauler and permitted Treatment, Storage& Disposal Facility: ? /G <br /> Hauler Name£/2/c4a Y��GT ./ STS Hauler Registration <br /> # Vcy�T <br /> Address�/`"�t3pz /- //�0 ri City �G�// Zip <br /> Phone No. (� ) �CJ -�o I�� �� / <br /> Permitted Disposal Site Dk 0/X 6A) / CW642 OA J)1re J G4•2�6 2-67 <br /> 707-6934 er'y " 7©BOO/L6oZ <br /> 8. a. Describe the method that will be utilized to purge and/or inert the to (s): <br /> /Cg ial- (3E 7 TSF A;; 47s moi= <br /> b. Tank/Piping Hauler: <br /> Name <br /> ff <br /> Address (�D K 35 � City e—, e,42 Zip <br /> Phone No.-,�- 49 ,�,1 1 t,,, _/ <br /> Hauler Registration #(if hauled as hazardous)���`�� �JU(//IYDr(,rWX, � ��715- <br /> EH 23 046 (Revised 10/30/12) 4 <br />