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1. (a) is there a PHS EHD contractor's and subcontractor's questionnaire on Elle or enclosed? YES K NO[] (b) Is the current certificate of worker's compensation Insurance on file? YESJ4 NO(] (c) Does the contractor possess a"Hazardous Substance Removal Certiflcation"? YES NO[] (d) Has everyone on site,Including cranelbackhoe operator,been certified to work on hazardous waste site In accordance with CCR Title 8? YES)} NO[] 2. Has a"Site Health&Safety Plan" for this Job site been submitted? YES fd NO[] 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? 7� NIA-L,f YES[] NO[] If YES, Permit# 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA) YES[]NO[] 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain)YESY. NO[] S,4 6. If tank residual exists,Identify transporting hazardous waste hauler. Name CA L Ot L Hauler Registration# C/}0 9 8 Z4 Address P. Qd (9 4 3 city ' {}!6Z Zip S 3/ ( 7 Phone#( poo 1 3� Z — D7 ` C) 7. Decontamination Procedures: a. Will tank(s)and piping be decontaminated prior to removal? YES).(NO[] b. Identify contractor performing decontamination: Name /U)V/hJCEL) G�D� lJ�� yl/tlewf'� , SA)CC Address 400!; /J . tA) k 0/n1 OV, City Sir r r ) Zlp C/SzC Phone No4 20`T ) �L 7 -�C�o C. Describe method to be used for decontamination f,pnJS4�L, tJ i f-t� C�-RZ_AL v� I�ArJ SD/+ P SD�a F6Q� d. Describe how rhtsate material will be stored onsite prior to manifesting offsite: 4j� a/e l's-t/Jc��' %syd p'✓`^�'. rN �E-;�� l�le4d'Yl US�� VAC ULAM 'MOCK e. Rlnsate Hauler and permitted Treatment. Storage&Disposal Facility: Hauler Name N0C— CAL V/ Hauler Registration# 6041). Address F 0. G� �0 City DL/JA Zip q> /l1� Phone No. 9 d 3 ,32- - �1 210 Permitted Disposal Site GAJ D tl $f r(it L SL-12✓l 66� 0/L C O EH 23 046 (Revised 10119198) Page 4