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�,. . W <br />1. (a) Is the current certificate of worker's compensation insurance on file? YES [ ] NO[] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ ] NO[] <br />(c) Has everyone on site, including crane/backhoe operator, been certified to work on <br />hazardous waste sites in accordance with CCR Title 8? YES [ ] NO[] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [ ] NO[] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A [ ] YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [ ] <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name 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[] NO[] <br />b. Identify contractor performing decontamination: <br />Name <br />Address City Zip <br />Phone No.( ) <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Hauler Registration # <br />Address City Zip <br />Phone No. ( ) <br />Permitted Disposal Site <br />8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br />b. Tank/Piping Hauler: <br />Name <br />Address City Zip <br />Phone No.( ) <br />Hauler Registration # (if hauled as hazardous) <br />EH 23 046 (Revised 10/30/12) 4 <br />