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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? (b) Is the current certificate of worker's compensation insurance on file? (c) Does the contractor possess a "Hazardous Substance Removal Certification"? (d) Has everyone on site, including crane/backhoe operator, been certified to work on hazardous waste site In accordance with CCR Title 8? 2. 3. 4. 5. Has a "Site Health & Safety Plan" for this job site been submitted? Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? NIA [ ] YES[] NO[] If YES, Permit # YES[] NOI]I don't know YESM NOII YES D1 NO[I YES [7J NO[] YESDJ NO[] Has the contractor obtained approval from the local fire department to perform tank cutting? NAN YES[ ] NO[ ] Is there knowledge or evidence of leakage from the tanks) andlor piping? (If yes, please explain) YES I ] NO M 6. If tank residual exists, identify transporting hazardous waste hauler: Name Evergreen Environmental Hauler Registration# 0242 Address 6880 Smith Avenue City Newark ZiP 94560 Phone#( 800 ) 972-5284 7. Decontamination Procedures: a. Will tank(s) and piping be decontaminated prior to removal? YESM NO [ I b. Identify contractor performing decontamination: Name Savidge Construction Address4401 Sonja Court Phone No.( 530 ) 622— c. Describe method to be used for decontamination: Steam cleaning City Placerville Zip 95667 d. Describe how Ansate material will be stored onsite prior to manifesting offsite: In 55 gallon drum e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name Evergreen Environmental Hauler Registration# 0242 Address 6880 Smith Avenue City Newark ZIP 94560 Phone No. ( 800 ) 972-5284 Permitted Disposal Site Rinsate is recyled at same site. Ell 23 046 (Revised 08113199) Page 4