REMOVAL_1997 TEMP CLOSURE - Laserfiche WebLink

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NIA 1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES [ J NO [ J (b) Is the current certificate of worker's compensation insurance on file? YES [ j NO [ j (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ ] NO [ ] (d) Has everyone on site, including crane(backhoe operator, been certified to work on hazardous waste site in accordance with CCR Title 8? YES ( J NO ( ] 2. Has a "Site Health & Safety Plan" for this job site been submitted? NIA YES [ J NO [ ] T Aa K to O F i3't-:u G k&r-10.�" 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? N/A ( ] YES [ ] NO [ ] If YES, Permit # 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAl ] YES[ ] NO( ] 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES K] NO [ ] jcjnt,i,, a clot b1e WLN\ Fiberc�IM-5 00h( u.al\ hg-, h-2 ED Coni rMe I 1 ecik maker l f rine From the int etst t 4 UL ��otr• the lnlertnr t5 noF letxktnt�_ 6. If tank residual exists, identify transporting hazardous waste hauler. N ` A Name Hazier Registration 9 Address City Zip Phone # ( ) De ntamination Procedures: a. Will tank(s) and piping be decontaminated prior to removal? NIA YES [ [ NO [ J FOP, T&Ykxgbra.ioaL1 c[o5t. onLh • No UrIVr-aL C) l TO i5 b. Identify contractor performing decontamination: 1,1 Name Address City Zip Phone No.( ) C. Describe method to be used for decontamination: d. Describe how rinsate material will be Mored onsite prior to manifesting offsite: e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: �) l I 19 Hauler Name Hauler Registntion I Address City Zip Phone No. ( ) Permitted Disposal Site EH .3 046 (Revised 7/10/96) Page l