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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES j NO [ j (b) Is the current certificate of worker's compensation insurance on rile? YES [ j NO (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES.q NO I I (d) Has everyone on site, including crane/backhoe operator, been certified to work on hazardous waste site in accordance with CCR Title 8? YES [ I NO [ j CANNOT ANSWER AS NO ONE IS ON SITE YET. 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES IA NO 11 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? N/A [� YES I I NO [ I If YES, Permit # 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[Xj YES[ I NQ I TANK TO BE REMOVED FROM SITE 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ j NO�3 6. If tank residual exists, identify transporting hazardous waste hauler: Name SAME AS 7 CES Hauler Registration # Address City Zip Phone # ( ) 7. Decontamination Procedures: a. Will tank(s) and piping be decontaminated prior to removal? YES [X1 NO l I b. Identify contractor performing decontamination: Name JAMES J. HOBLITZELL Address P.O. BOX 30331 City STOCKTON.CA Zip 95213 Phone No.( 209 ) 943 7793 C. Describe method to be used for decontamination: USING HIGH PRESSURE HOT WATER CLEANER USE NON CHLORINATED CLEANER AND RINSE TANKS THREE (3) TIMES EVACUATE TANK BY VACUUM TRUCK AND OFF HAUL FOR DISPOS< d. Describe how rinsate material will be stored onsite prior to manifesting offsite: WILL NOT, SEE ABOVE e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name NOR CAL OIL Hauler Registration # 2412 Address BOX 645 City DENAIR ,CA Zip 95316 Phone No. ( 800 I 332 8710 Permitted Disposal Site nn For ni ni Goc;n ni won ,g norvF cri vER coot IQ9 � 01EWIDA li29 - -- 5/20 EH 23 046 (Revised 9/11/96) Page 4