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1. (a) is there a PIIS-EIID contractor's questionnaire on file or enclosed? YES)q NO [ ] <br /> (b) is the current certificale of worker's compenaallon Insurance on Mel YES� NO [ } <br /> (c) Does lire contractor possess a 'hazardous Substance Re.raval CeefiWicatlon'7 YES� NO [ } <br /> 21 lies to 'Site Ilea1W A Safety 11an' for this Job site been submitted? YES X NO [ } <br /> 3. lins applicant performing removal In ilia oily of Tracy obtained a 'Grading and Excavation Permll'7 <br /> N/A r1 YES { [ No 1 1 If YES, 1'ermll # <br /> 4. lies flit contractor oblshrcd approval from the local fire department to perform lank culUug7 HAAYES[ J N0, <br /> S. Is there knowledge or evidence of leakage from the lank(s) and/or piping? (If yes, please explain) YES [ [ NO <br /> 6. if lank residual exists, IdenHf7 transporting harardous waste haulm <br /> Name Not--C11 WSrsLc Oi 1 1011lM•3 Ilaulcr Rg0sfrallon ff CAI) 9921117255 <br /> Address P.O. Box 645 City Denair•, CA Zip 95316 <br /> Phone * ( 209 1 3:1:? Cl't to <br /> 7. Decontiminadon rtoeedurm <br /> e. 1VIII lank(s) and plping be decoulamhreted prlor to removal? YES � NO [ } <br /> It. identify confrocior performing decontaminaliont <br /> Name Jim Thorp(! 011 , Inc./ DILA Ilich—KirL Cowsl.ructiorl <br /> Address 351 IJ. lreclanaul 11d./ P.O. Mix 357 City Lod I ,CA Zip 9521r 1-0357 <br /> Phone No.( 2O9 ) 462-16M J'TO/I1i91: 11az, i1 rl, . hat?l er• 11 2667 <br /> c. Describe orelhod ja be d for deconlaminallonr <br /> Uri File aL HIS/ rI�) <br /> d. Descrfl►e how tfnsele mnlerisl will be stored onslte prior to maniresiing oRshei <br /> The t-iiigl-al.e: Will 110 r-cHUMed by Jim •1'hurve 011, llic. perswel alid placed .lac <br /> tllrt7rig_ The cltisnv wi I1Jlr, Li'arstgrr 4esj by us toour• yard aL 80'j [flack U1_auptid <br /> Way, Lodi r CA Lo awa1L pick iip by a qualified collecLloii cmpariy. ENA #CAL 0000128011 <br /> e. Rinssle Hauler and p" filed 'I'reslment, Storage & nlsposal F oicilitrl <br /> Ilauler Name Sariie as # 6 Hauler Rteslration +R <br /> Address City ZIP <br /> I'llone <br /> rermlited Disposal Site Refilieries Services VaUerson, _CA or oLher approved facility. <br /> Page 4 <br />