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0 <br />0 <br />1. (a) Is there a PHS-ERD contractor's and subcontractor's questionnaire on file or enclosed? YES Jd NO I ) <br />(b) Is the current certificate of worker's compensation Insurance on file? YES N NO I J <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES No[] <br />(d) Has everyone on site, including cranefbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES NO [ ) <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES Vl NO[] <br />`mac 4".j C Vj_N,'FHS-€,+,3-/Im,...n <br />3. Has applicant performing removal In the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIAX YES II NO(J It YES, Permit# _j¢.Z a }-c.�L,A <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ I YE*NO[ 1 <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? Of yes, please explain) YES 11j, NO I ] <br />/95 eQ,L „Sea b 74I -e 2 I . S Sc A�_ r-e.s,,I+s <br />6. If tank residual exists, identity transporting hazardous waste hauler. <br />Name M P r- v, J I r r� 0,-,, 4 ( IZt, Hauler Registration / Z 6 SS <br />Address 3�(o0 M�-� City C. �Pr�i-�� (CZIp 9Q 3o <br />Phone # ( (,,, (r 1 ) 3 S -� — C.) SO 8 <br />Decontamination Procedures: <br />a. Will tanks) and piping be decontaminated prior to removal? YESA NO I J <br />b. Identify contractor performing decontamination: <br />Name M _(2' I` V, sN ✓- ,. n..t„ I , , T/�_ <br />Address 0 dV\ C� U. o-- , -FCity IJ a IW c ZIP 9 9 3 o Y, <br />Phone No. ( ) 3 9 . — 0 5'0 �3 <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility. <br />Hauler Name /An �slr�„ rv,µ-rc,� I ;mac HatlerRegisstration/ Zc6`7 <br />Address_34o O /I,1c,S T City c lc.R/s 17.E �� '(gyp Q <br />Phone No. 39 3- o S vP, <br />Permitted Disposal Site Cc"� -1 A3.ri;e„� Lc,-f� I tc.l, _6-12/} <br />EH 23 046 (Revised 08113199) Page 4 <br />