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M <br />1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YESJ* NO [ ] <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 ] NO [ 1 <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$ 1 NO 11 <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES; 1 NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A PCI YES i ] NO [ i If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? N&[x1 YES[ 1 NO[ 1 <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I ] NOK 1 <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />None 644 /moo ctFzq)7Z� <br />Name /��,�'r" Hauler Registration # V t � <br />Address Bois Wy7s CityZip-�� <br />Phone # ( 9 ) F�7 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES ki NO I ] <br />b. Identify contractor performing decontamination: <br />Name Advanced Geo Environmental <br />Address 4005 north Wilson Way City Stockton Zip 95205 <br />Phone No.( 209 ) 467-1006 <br />C. Describe method to be used for decontamination: <br />triple rinse UST and lines with detergant and purge waste <br />wat'Pr for rJiqPnqAl <br />Cd. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />purge water from UST immediatel 3 <br />- c <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Nor Cal Oil Hauler Registration #CAD 98241 7255 <br />Address pn nnx 6q.s CityD�n ai QA Zip <br />95316 <br />Phone No.( 209 ) 677-6692 <br />Permitted Disposal SiteAm ri lPan 7570 Almond „_..__ Springs <br />NV <br />5/20 r <br />EH 23 046 (Revised 9/11/96) Page 4 NVD982358483 <br />