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i 1. (a) Is there a PHS•EHD contractor's and subcontractor's questtonnalre on file or enclosed? YES NO[] (b) is the current certificate of worker's compensation insurance on file? YE SX NO[I (c) Does the contractor possess a"Hazardous Substance Removal Certlficatlon"? YES;K. NO[I (d) Has everyone an site,including cranelbackhoe operator,been certified to work on hazardous waste site In accordance with CCR Title 8? YES NO[] 2. Sas a"Site Health&Safety Plan"for this job site been submitted? YES)( NO[ 3. Has applicant performing removal In the City of Tracy obtained a"Grading and Excavation Parmit"? NIA t YES[] NO[I If YES, Permit# 4. Has/_the contractor obtained approval from the local fire department to perform tank cutting?N3KYES[]NO[] 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? Of yes,please explain)YES[] N0) 6. If tank residual exists,Identify transporting hazardous waste hauler. Name Q M er�GA r\ Va h ey L,1 aS+e. O t' l Hauler Registration# { Address P.O . L3 0 340 city e t h; zip Y5- �s i Phone#[ 800 I 7 3 2- — 'I Co 115 i 7. Decontamination Procedures: a. Will tanks)and piping be decontaminated prior to removal? YESA NO[] b. Identify contractor performing decontamination: f Name Y 4 1 V e jinae-r;rt �- - Address I V5 9 Ly G er A e- Ay e- City 5+-as,K+-oh zip 15-AO3 Phone No.( o O_'J I y� y C. Describe method to be used for decontamination: 5}ectr+-\ CiecA d. Describe how Ansate material will be stored onsite prior to manifesting offsite: Q+n5OL 1?ung a -nt a rave auIer. e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: Hauler Name A rr1er i e cA eA VG i IffC Hauler Registration# 3-7"- Address 7y yAddress P. 0. 6 o X 3 �o city N i L. - zip 95 3)5- Phone Phone No. g{ 0_) -7 3 2` �&4k5- 4 Permitted Disposal Site Lyer6o�w A:�- 0 9 7t'ar•c FC EH 23 046 (Revised 08113199) Page 4