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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />YES /NO [ ] <br />(b) Is the current certificate of worker's compensation Insurance on file? attached YES [(`f NO <br />(c) Does the contractor possess a 'Hazardous Substance Removal Cion? YES p(J INO <br />2. Has a 'Site Health & Sa" Plan' for this Job site been submitted? <br />I <br />U <br />YES [( NO[ ] <br />3. Has applicant performing removal In the City of Tracy obtained a 'Grading and IEueatlon Permit'? <br />N/A [X] YES [ ] NO [ ] If YF -9, Permit # <br />0. the contractor obtained approval from the local fire department to perform tank cutting? NAD3.Ml ] NO[ ) <br />S. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [)I <br />6. If tank residual exists, Identify transporting hazardous waste hauler. <br />Name Vander Pol Enterprises Hauler Registration # <br />Address 1001 W. Charter Way Cit? Srnrkrnn ZIP 95901 <br />Phone # ( 209 l 465-3421 <br />7. Decontamination Procedures <br />a. WIII tank(s) and piping be decontaminated prior to removal? OYES NO I ) <br />b. Identify contractor performing decontamination: <br />Name Paydirt Excavating Co. Inc. <br />�// Address 259 Oregon St, City Ripon Zip 95366 <br />Phone No.( 209 l 599-2347 <br />C. Describe method to be used for decontamination <br />`Tanks will be triple rinsed. <br />dDa�16e how Ansate material will be stored onelte prior to manifesting olfeitm <br />ansate will not be stored onsite. The rinsate will be pumped <br />directly trom tans to vacuum truck and hauled away. <br />e. Rlnsate hauler and permitted Treatment, Storage & Disposal Facilityl <br />Hauler Name REfinery Services gaoler Registration # 2591 ## <br />Address 13331 N. Hwy 33 Citi Patterson Zip 95363 <br />Phone No. 800 ) 874-4444 <br />Permitted Disposal Site 13331 N. Hwy 33, Patterson, CA 95363 <br />## EPA # CAD083166728 Page 4 <br />