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[] <br /> 1. (a) Is the current certificate of worker's compensation insurance on file? YES NO <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES NO[] <br /> (c) Has everyone on site,including crane/backhoe operator, been certified to work on YES ^ NO[] <br /> hazardous waste sites in accordance with CCR Title 8? <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YES K NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/AX YES[] NO[.] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAS(]YES[] NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES[] NOX <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> Name� Gw C ZQ yyG�JJs HaulerRegistration# /3 <br /> Address 1/0A inaL"1 o6 Z- City //AG /e- r l zip 8 <br /> Phone#(.3/0 ) �Z-3 0 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YE NO[] <br /> b. Identify contractor performing decontamination: <br /> Name G yn/e (��ca•�/n ovs <br /> Address -110bl, E A44i>nAYly 41, city cr Zip ge: � ZEDS <br /> Phone No.( J �(� ) S 2 S ��7t_S D <br /> C. Describe method to be used for gecontamination: <br /> d. Describe how r.nsate material will be stored onsite prior to anifesting o ite: <br /> 6 M <br /> e. Rinsate Hauler and permitted Treatment, Storage isposal Facility: <br /> Hauler Name .c:' HaulerRegistration# !� 7.8 7,5 <br /> Address 7-000 /v !� City Co A4roM zip 10 zL4 <br /> Phone No. ( ) <br /> Permitted Disposal Si <br /> 8. a. escribe the method that will be utili d to urge anc] r/or in� e tantk�s): <br /> P C 'T <br /> b. k/Piping Hauler: <br /> Name 14 1✓1c� Ai c r �( J <br /> Address -VO� c Z City Czip <br /> Phone No. J s z 3 �y3a <br /> Hauler R stration#(if hauled as hazardous) <br /> EH 23 046 (Revised 10/30/12) 4 <br />