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1. (a) Is there a PIIS-EIID contractor's questionnaire on file 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 'Dmrdous Substance Removal Certi6otlon'? YES NO ( 1 <br /> 2. Has a 'Site Health &Safety Plan' for this Job site been submitted? YES NO ( ] <br /> J. fins applicant performing removal in the City of Tracy obtained a 'Grading and Encavadon Permit'? <br /> N/AA YES ( I NO ( I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local Ore department to perform tank cutting? NA, ( YES[ I NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ j NOA <br /> 6. If tank residual exists, Identify transporting hazardous waste haulen <br /> Name Nor-Cal Waste Oil Haulers ILvIQ Registratiom # CAD 982417255 <br /> Address P.O. Box 645 City Denair, CA Zip 95316 <br /> Phone # ( 209 ) 332-8'T 10 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES 1$ NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name J.im Thorpe Oil , Inc./ DBA Rich-Mart Construction <br /> Address 351 N. Beckann Rd./ P.O. Box 357Clty Lodi ,CA Zip 95241-0357 <br /> Phone No.( 209 ) 462-4581 J'r0/13MC 11az Mat. hauler (? 2667 <br /> C. Describe method to be used for decontamination: <br /> Ou Pile at PHS/EHU <br /> d. Describe how Ansate mnterinl will be stored onsite prior to manifesting offsite- <br /> '111P r i uvPa i.e will be rPmOy i by Jim Th r,oe Oil Inc oersonel and placed in <br /> durms_ The drums will be transported by us to our yard at 807 Black Diamond <br /> Way, Lodi, CA to await pick up by a qualified collection company. EPA TICAL 000012884 <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Same as 1) 6 Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposnl Site Refineries Services Patterson, CA or other approved facility. <br /> Page 4 <br />