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(a) <br />Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />YES <br />NO I J <br />(b) <br />Is the current certificate of worker's compensation insurance on file? <br />YES <br />NO I J <br />(c) <br />Does the contractor possess a "Hazardous Substance Removal Certification"? <br />YES J <br />NO ( I <br />(d) <br />Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />YES <br />NO ( <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES K NO ( I <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A I I YES I I NO J] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAI I YESX NO[ <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I J NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name AMtFICAN VALI LY b�VIRON MENiflL Hauler Registration # 2-`IS3 <br />Address 2`130 (1I;ER 1Zt7• $LD&. I5(p:L- City TuRLIXY Zip cts380 <br />Phone # ( Zo`I ) ctll-7 L0I oY Lt4 732- 4L-,45 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES �(J NO I I <br />b. Identify contractor performing decontamination: <br />Name - 4,4� 4A- E) <br />Addresszip <br />Phone No.(->JQ �? <br />C. Describe method to be used for decontamination: <br />' P-IPLE 4ZtN5t WIrH NOT t1-'-E-45LARF W65HER <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />ZEN1nVED FRnM 1A5T NSicy4- VAC. TR.Lt.CK — 5TCT-ED IKI 55— GILL <br />U vr15 oR -ft2FFN SDORTs=D DIF-E(TLY TO FA e -14i TY IN Ufte-- -i -K <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name AMERICAS VALLEY Hauler Registration <br />Address 3o (9 EER Pb R L-D(n. 151, City i uR LOC L Zip ci538b <br />Phone No. ( Z1 -q ) �E3 - 7(00 1 <br />Permitted Disposal Site FIR /_I� .r <br />V` <br />5/20 <br />EH 23 046 (Revised 9/11(96) Page 4 <br />