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• YES lx) NO [ [ <br /> uesllonnalro on file or enctosedT YES NO [ [ <br /> is there a PIIS-EiID contractor's 9 Insurance on file?(b) Is the current certllicate of worker's compensation YFs NO [ <br /> �pnuon'1 <br /> Substance Rmwvw No [ <br /> (c) goes the contractor possess a "llrnrd°u° YES [yl <br /> 2, pas a .Site Health R 9aMy rW for tills Job site been submitted? <br /> y llas applicant performing re"o[ 1 the Clly if Tracy petnult #a �CradlTrR and <br /> ra/lon Permit'? <br /> ained <br /> Ir YES, MI I NOI I <br /> NIA YE9 [ ) <br /> royal from the local Aro department to perform lank culling? NA NOW <br /> 4. Ilan the contractor obtained aPP es, lease explain) YES [ 1 <br /> s, is there knowledge or evidence of leakage from the tank(e) and/or plphrgT (Ir y P <br /> (dual exists, ldenlify transporting <br /> hazardous waste haulersCA982417255 <br /> 6, <br /> if tank res Hauler <br /> Rrglatratlon #.-------- <br /> Name - Oil Waste oil hauler r 16 <br /> Clly LL a ZIP 9� <br /> Address <br /> 2-8 10 <br /> Phone # O <br /> 7. Mcmitamlmatloa Pr°°edurau yFS [ NO I 1 <br /> A. Will tank(s) and PIPing be decont <br /> aminated prior to removal? <br /> b. Identify contractor Performing decontaminallont <br /> Name Jim 'Tolle Oil, Inc./ DBA Lich-Mart Construction <br /> Chy <br /> Lodi Zlp 9524 --• <br /> Address 351 N f3eclonan Rd <br /> 209 368-6175 / 462-4581 <br /> Phone No.(__) <br /> ion. <br /> G DeRcribe method to be used for deconlaminauo1, ideals. <br /> 11 <br /> d, Describe how rinsate material will be stored onsite prior to manifesting ottslla <br /> Rinsate will be stored in it <br /> e sealed and labeled until tun <br /> Itted Treatment, Storage ds Disposal Faclllly, <br /> e. Iilnsate Ilauter and perm tion # CDD 9L2 n255 <br /> heeler Registra <br /> Hauler Name No - oily Zip 95316 <br /> Dettai� <br /> Address ' <br /> Phone No. (__ZQj(__j _g <br /> 7 IQ .calif <br /> Permuted Disposal Site <br /> Refine[ Patterson Ca or other aooro' I f <br /> Page 4 <br />