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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ ] <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES NO [ ] <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES { NO ( ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A [ ] YES [ ] NO [ 1 If YES, Permit N <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAXYES[ ] NO[ 1 <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES 1 ) NOX <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name Hauler Registration # <br /> Address City Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedures: zA114 <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES 1 ] NO 1 ] <br /> b. Identify contractor performing decontamination: <br /> Namew � <br /> Address SIJ S . 7Li1✓ City Zip 9S6 l` l <br /> Phone No.( <br /> C. Describe method to be used for decontamination: All ` <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: /^ <br /> . ddd'T <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />