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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES [ ) NO YV <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [ ] NO <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ J NO <br /> (d) Has everyone on site, including crane/backhoe operator, been certified �,{ <br /> to work on hazardous waste site in accordance with CCR Title 8? YES [ ] NO XV <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? 19IV c/ipd YES NO [ J <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/AX YES [ ] NO [ J If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAXYES[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ J NO X <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> lVo r-e;5%olva <br /> Name Hauler Registration # <br /> Address City Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedures: LL JJ <br /> CtA�I�GIOry�»Ci7T, <br /> a. Will tank(s) and piping be decontaminated prior to-remeual2- YES [ J NO"—, <br /> b. Identify contractor performing decontamination: <br /> Name L2ar'Uta 4/- Z -Ze-. <br /> /� L u <br /> Address /PV• Ooe �y20 / City f/'Pm+�/1( Zip <br /> Phone No.( P/00 ) ���36o-Z(y <br /> c Describe method to be used for decontaminatio <br /> /�'1fY i/QCUII/hP� i7JTa�7�7�Arr <br /> d. Descr�}*be how rinsate material will be stofed onsite prior to�ma�nifes�t�ing offsite: <br /> f`Y�v y 6"zri Pc /%J X.,X si 7Cu�< <br /> 7'i72G /^i SirMo <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name L/c?Siz�w7�� �✓i%an��+/h/Haaler Registration #3,5--1S- <br /> 7 <br /> Address/. Q, Zge5 27 City �77?m�»T zip 9Y-�7- 57 Y20 <br /> Phone No. 17f7 yyy��/ `�� -.36 Z6 <br /> Permitted Disposal Site <br /> EH 23 046 (Revised 7/10/96) Page 4 <br />