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1. (a) Is there a PIIS•EIID contractor's questionnaire on rile or enclosed? YES U NO [ 1 <br /> (b) Is the current czrtiricate of worker's compensation insurance on rile? YES" NO [ 1 <br /> (c) Does the contractor possess a 'Hazardous Substance Ream"d C t0c`1k"0? YESM NO [ J <br /> 2. Has a 'Site Health & Safety Plan' for this Job site been submitted? YF-*Jot NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit! <br /> N/A)W YES [ 1 NO [ 1 If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAM YES[ 1 NO[ ] <br /> S. 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 /> ExistiDg diesel in UST will be filtered & transfere�tttl w �ul AST. <br /> Name <br /> Address CityZip <br /> Phone # ( ) <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? It ES NO [ 1 <br /> b. Identify contractor performing decontamination: <br /> Name Tom Mehrinopr ron^`^'^~ion, the <br /> Address 1820 Bidwell ctrept City Red Bluff CA Zip 96080 <br /> —_� <br /> Phone No.(_ 916 ) 927-5014 — <br /> c. Describe method to he used for decontamination: <br /> pry jCe will be used to inert }ark and then tank & a"_1 ririta will be __ <br /> fl ,sh�+ile rinsed with deterapnt under pressure, before removal <br /> from site. <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> Rincatp material will 1�- manifested & ra_ncmrted aloud With the <br /> Pxrayatpd tank by sarin anvernment mritractor. <br /> e. Rinsate Hauler-and permitted-Treatment, Storage &Disposal Facility: <br /> Hauler Name H ! x Trnrki na Hauler Registration # 401991 <br /> Address 720 Terry A Francois St. City San Francisco Zip 94107 <br /> Phone No. 415 ) 905-5510 - Attn. Mary T.ou or Sue Parsons <br /> Permitted Disposal Site to be determined by governmental disposal contractor <br /> Page 4 <br />