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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire an file or enclosed? <br />YES [A NO ( ] <br />(b) Is the L"arrent certificate of worker's compensation insurance on file? <br />YES W NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />YES fA NO ( ] <br />(d) Has everyone on site, Including cranelbackhoe operator, been certified <br />to work on hazardous waste site In accordance with CCR Title 87 <br />YES ( NO [ ] <br />2. Has a "Site Health & Safety Plan" for this Job site been submitted? <br />YES NO [ ] <br />3. Has applicant nerforming removal In the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA)( YES NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAP(YES[ ] NO' <br />5. Is there knowledge or evidence of leakage from the tank(s) andfor piping? (If yes, please explain) YES (] NO <br />6. If tank residual exists, Identify transporting hazardous waste hauler. <br />7 X75 C. , /, / <br />Name AIn l Cel✓l - � O I t-- Hauler Registration # `f y <br />! <br />Address f , O , 130 ^ S C/D City � �N 1 <br />/3�� <br />Zip q ,-s 3 is <br />/ cis <br />Phonefl boo sa— �l o ct s <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />YES bd NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Sal0c) <br />Address 1217 South 7th Street Cit, Modesto <br />Zip 95351 <br />Phone N04 209 ) 524-9653 <br />C. Describe method to be used for decontamination: <br />The tanks &_piping will be triple rinsed at 180° using a low volume, <br />high pressure washer. The first rinse will include the use of a bio- <br />degradable detergent. The two final rinses will be clean water. <br />d. Describe how Ansate material will be stored onsite prior to manifesting offsite: <br />The rinsate material will be stored on site in DOT 55 gallon drums <br />with Apprnnriatp lahple_ <br />e. Rtnsate Hauler and permitted Treatment, Storage & Disposal Factllty: <br />Hauler Name qM6[ '/Vev011-tt / DIS- Hauler Registration # <br />Address -P,a O . go � I e city 1)Gy([ Zip <br />Phone xo. ( Zoo) <br />Permitted Disposal Site OIL /-VC <br />EH 23 046 (Revised 10119198) Page 4 <br />