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i, (a) Is there a PHS•EHD contractor's and subcontracmrs questionnaire on file or enclosed? YES M NO [ ] <br />(b) Is the current certificate of workers compensation insuraacs on file? YES N NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Ramoval Cerdf1=10R"? YES M NO [ j <br />(d) Has even, one on site, Including crane(backhoe operator, been terrified NO <br />[ j <br />to work on hazardous waste site in accordance with CCR Title 57 <br />Z. Has a "Site Health & Safety P1a11" for this lob site been submitted? YESlj NO [ ] <br />S <br />Has n11=1 perforaing removal in the City of Traty obtained a "Grading and Excavation Permit"? <br />Ni . Yrs [ J No [ J u YES, Permit <br />Has the contractor obtained approval from the local fire department to perform tank cutting" NA47ES( ] NO( I <br />S. Is that. knowledge or evidence of leakage from the tanks) andlor piping? (II les, please explain) YES (J NOV <br />G. <br />7 <br />I <br />If tank residual exists. identify .:aaspordng hazardous waste Sauter. <br />Name NorCal waste Oil Haulers <br />P.O. Bol 643 <br />Phone 4f 800 332-3710 <br />Hauler Resstadon4 CAD 982417255 <br />My Denair, CA ZIp 95316 <br />Decontamination Procedures: <br />a. will tanks) and piping be decontaminatad prior to removal? <br />b. Idendl7 contractor performing decontamination <br />Name Jim Thorpe Oil, Inc. <br />Address <br />P.O. BOY 35 <br />Phone No. 209 ) 365-6175 <br />YES[a NO[I <br />City Lodi, C9 Zip 90240 <br />c. Describe method to be used for decontamination <br />Tarn(s) and piping will be triple rin <br />soaa solution and not weer. <br />d. Describe bow Ansate material will be stored onsite prior to manifesting offsite: <br />The rinsate will be removed from the tank(s) as it i= XPi r- <br />aeiivered to the oocosite end of the tank. <br />e. Rlnsate Hauler and permitted Treatment Storage & Disposal Facility. <br />Hauler Vane Same as =6 Hauler Ragist�adon t <br />Phone No. <br />able <br />Pe:mitedDisposal Slte AMe r' c I c a Trc 9 —n eimnrr <br />or other approved facility. <br />Ell 22 046 (Revised MIMS) Page 4 <br />