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1. (a) <br />Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />YES Iq' <br />NO I I <br />(b) <br />Is the current certificate of worker's compensation insurance on rile? <br />YES JX <br />NO I <br />(c) <br />Does the contractor possess a "Hazardous Substance Removal Certification"? <br />YES ISI' <br />NO I I <br />(d) <br />Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />YES I�( <br />NO I <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES JW' NO I <br />3. Has ap scant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A I� YES I I NO I I If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAI I YESIKNOI 1 <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I I NO I✓I <br />6. <br />7. <br />If tank residual exists, identify transporting hazardous waste hauler: <br />Name &- --/Y,MuierKegrsrrau <br />Address 6� Sj%—J'M/T/7� /Q ✓t CityA14W,,92.A-- <br />Phone # ( Bzn�fp) 97Z — SZ 8 g <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: / <br />Name .B -C GO <br />3aGZ <br />9¢60 <br />YESX NO l I <br />Address B`� �OP.P/4/��/�yE' Z/. sty S7�". � Zip '%I'ZA7 <br />Phone No.( -:2P9 ) 9J¢—�Zzi <br />C. Describe method to be used for decontamination: <br />7-.PI00L4EV' ,t�i�s'�" - <br />d. Dwibe how rinsate material will be stored onsite prior to manifesting offsite: <br />/1�D A•r13/Te� /�JA%cPiFT� CraR1'r i.Gry .i2/.t%.S'�9T� <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name -Z- > Z—' Lllleez? ,Hauler Registration M a�i�3`�Z <br />Address 6SCJc/ <J#!/T/V ry'*��T.� p. City /y�L- Zip <br />Phone No. (1 ' ooh 9'%Z. — S1 -O 14 <br />Permitted Disposal Site Alw4ezmwe� <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />