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1. (a) Is there a EHD contraq„ id subcontractor's questionnaire on file or L/ ;d? YES bd NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES bd NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [X] NO [ ] <br />(d) Has everyone on site, including crane/backhoe operator, been certified to work on <br />hazardous waste site in accordance with CCR Title S? YES Pq NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES N NO[] <br />3. Has,apUlicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />MAIN, <br />YES r NO [ ] If YES, Permit # yet <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAC4 YES[ ] NO[ 1 <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES[ ] NO DQ <br />6. If tank residual exists, identify transporting hazardous waste hauler:I �9iS fQirnn IPS <br />qp c.Pii 0fibO28•Zl?.•U3in _ (�tz0159 <br />Nahtn �X4 /nytrOY)lo{al seryir-PS r. ,Hauler Registration <br />Addresses 2- GQ�,$leld AVC. City !?Qr� Zip <br />A <br />Phone # ( Z ) _Z 3 i .15SD <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES >4 NO [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />Address <br />Phone No.( 2t, 01 <br />C. Describe method to be used for <br />Q <br />C. <br />13 <br />City Tac 4 Zip qVJ <br />LI <br />Rinsate Hauler and permitted'1'reatment, Storage & Disposal Facility: 3 <br />I yr {hQ <br />Hauler Name �UA1 ! QJM 1 VI CtS AH+auler Registration # Q _ <br />Address__q-3D2U�_fV <br />1Cla�'�e City0 10c Zip `10050 <br />Phone No. &L 3 Z S I ) 5 S <br />Permitted Disposal Site _N_P!9oJ doOn tr) lalq "MC ,08,352_ <br />Describe the method that wiillbeI utilized to purge and/or inert the tank(s): <br />l]eG� R 161-5L ]'�ji. ACA o'l t'Ca +' pit �4� 1G�uc d i•b) �'1��/ 'j <br />—1 <br />b. Tank/Piping Hauler: <br />Name f1 �� L i1� a <br />EH 23 046 (Revised 12/31/07) <br />Inc. <br />