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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES N NO[J <br /> (b) Is the current certificate of worker's compensation Insurance on file? YES N NO[J <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YESN NO[J <br /> (d) Has everyone on site,including cranelbackhoe operator,been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YEST] NO[I <br /> 2. Has a"Site Health&Safety Plan"for this Job site been submitted? YESj] NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA W YES I] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[VESJ]NO[J <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (I1 yes,please explain)YES[J NO[� <br /> 6. If tank residual exists,identify transporting hazardous waste hauler. <br /> Name American Valley Waste Oil HaulergaulerRegistration# CAL 000827878 <br /> Address P.O. Box 340 Cit, Delhi , CA Zip 95315 <br /> Phone#( 8OO ) 332-8710 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YESXY NO[I <br /> b. Identify contractor performing decontamination: <br /> Name Jim Thorpe Oil , Inc. <br /> Address P.O. Box 357 Cit, Lodi, CA yip 95241-0357 <br /> Phone No.( 209 ) 368-6175 <br /> C. Describe method to be used for decontamination <br /> Tank(s) will be triple rinsed with a biodeeradeable soap solution <br /> and hot water. The associated lines will be done in a similar way. <br /> d. Describe bow Ansate material will be stored onsite prior to manifesting offslte: <br /> Rinseate will either be removed from the tank and lines as they are <br /> being rinserl by tho waste bailler or st•9I'gcj in se 4-p_ � Inhl-ort until <br /> they can be pumped out . <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler NameAme r i can Valley W.O. Haulers HaulerReglstration# CAL 000827878 <br /> Address P.O. Box 340 City Delhi, CA yip 95315 <br /> PhoneNo.( 800 ] 332-8719 <br /> Permitted Disposal Site Americlean, Inc. 2570 Almond Dr. , Silver Springs , NV <br /> or other approved facility. <br /> EH 23 046 (Revised 08113199) Page 4 <br />