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1. <br />(a) Is there a PHS-EHD contractor's questionnaire on Ille or enclosed? <br />YES NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file' <br />YES NO [ ] <br />(c) Does the contractor possess a 'Hazardona Substance Removal Cerdflcadon,., <br />YES 1'f NO [ ] <br />'_. <br />Has a site Health & Safety Plan' for this job site been submitted?. <br />YES, NO [ ] <br />}. <br />Has applicant performing removal in the City of Tracy obtained a 'Grading and`F.ccavation Permit.' <br />N/AX YES [ ] NO [ ] If YES, Permit # <br />4. <br />Has the contractor obtained approval from the local fire department to perform tank <br />cutting? Nio YES[ ] NO( ] <br />�. <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO X <br />l 6.1 <br />`/ <br />If tank residual exists, identity transporting hazardous waste hauler. r/' A — <br />TA-N'C EDS P -N <br />Name Hauler Registration <br /># <br />Address City <br />Zip <br />Phone # ( ) <br />7. Decontamination Procedure <br />a. Will tank(s) and piping be decontaminated prior to removal? YFS [ l NO <br />b. Identify contractor performing decontamination: <br />Name eco L061�1 CGi-17LQ t_- ti (J vSiY/-( C',�, <br />Address Z� I �A�fZ n I.'�l,Vl n CityPl < H -No Mo Zip <br />Phone No.(S� <br />C. Describe method to be used for decontamination: <br />TMJ IL 121 N5 �o = � Pyr E: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite <br />�� ,C,'�,� — N 2 I N S 4 -TZ^ S --,-Z) rL cYJ CA <br />( e. l Rinsate Haulezand permitbed_Treatment,.Storage &.Disposal Facility: <br />`J Hauler Name i� L VU ;til �l E 1�-)i'rn— Hauler Registration # 7& 6 Z <br />Address I t I � C iK� Li h / a D� SM I (c � City I _t wR �C 2.� Zip 0M)� <br />Phone No. ( qrj <br />Permitted Disposal Site <br />Page 4 <br />