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1. (a) Is there a PHS-ERD contractor's and subcontractor's questionnaire on file or enclosed? YES M NO(] <br /> (b) Is the current certificate of worker's compensation insurance on file? YEW NO[J <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YESX NO[] <br /> (d) Has everyone on site,Including crauelbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title S? YES[Iq NO[] <br /> 2. Has a"Site Health&Safety Plan" for this job site been submitted? YES`f,N NO <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA RIS YES NO[] If YES, Permlt# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAq YES(]NO(] <br /> 5. Is there knowledge or evidence of leakage from the budga)andler piping? (H yes,please explain)YES(J NO( <br /> G. If tank residual exists,Identify <br /> transporting haaardoas waste hauler. t4JA <br /> Name Y Qmos , U irf)l)A&W Hauler Registration# <br /> Address J 5S R^�'I7ler7 sty% /�mfir Zip <br /> Phone#( <br /> 7. Decontamination Procedures: TV 9E i5m RESi \ <br /> a. Will tanks)and piping be decontaminated prior to removal? YESY( NO[] <br /> b. Identity contractor performing decontamination:( � <br /> Name gal r I SJff-rnl>:re)n Alp& / <br /> Address 0 E ( P' Jj • >(y��Q_City - /7no Zip <br /> Phone No <br /> c. Describe method to be used far decontamination: <br /> d. Debe how rinsate mateMl will be stored onalte prior to testin offslte: <br /> e. Rinsate Hauler and permitted Treatment.Storage <br /> __ y: <br /> &Disposal Facilit <br /> Hauler Name I n j �-Pw i t 191 yU 1 l Hoarder Reglatrration# <br /> Address /q f , 71_CIqdErPP_ �_ <br /> Phone No. 7 7)6/7 7 ) <br /> Permitted Disposal Site��6 ,i7�QnT�T/ 'W � �+1�G <br /> RE 230M (Revised 10119198) Page 4 <br />