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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES [ J NO J)J <br /> (b) Is the current certificate of worker's compensation insurance on rile? YES [ J NO [}J <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ ] NO J)J <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 ( i NO [)J <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES ( J NO ()J <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A ] ] YES [ J NO �] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAJ J YES( [ NO( ( <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ J NO <br /> TANK WAS NOT USED BY ME <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name NSA Hauler Registration # <br /> Address City Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES ( J NO ( J <br /> b. Identify contractor performing decontamination: <br /> Name N/A <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> N <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> N.1R <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name NSA Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> 50-_0 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />