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1 ' <br /> 1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO[[ <br /> (b) Is the current certificate of worker's compensation insurance on file? YES[] NO[1 <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES[] NO I] <br /> (d) Has everyone on site,including cranelbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 8? YES(I N0 I] <br /> 2. Sas a"Site Health&Safety Plan"for this job site been submitted? YES I I N0 I 1 <br /> 3. Has applicant performing removal In the City of Tracy obtained a"Grading and Bzcavation Permit"? <br /> NfA[1 YES[1 NO I 1 If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAI I YES[I NO[1 <br /> 5. Is there knowledge or evidence of leakage from the tanks)andlor piping? of yes,please explain)YES[] No I] <br /> _ 1 <br /> i <br /> 6. If tank residual exists,Identify transporting hazardous waste hauler: <br /> Name _` HaulerReglstratlon 0 c.A,1>`l�(;2"030 y`I 7j <br /> Address �> b city tZ1t' �flc,a it` Zlp_ A-4 <br /> I <br /> Phone#( Gt 0 <br /> 7. Decontamination Procedures: <br /> a. will tank(s)and piping be decontaminated prior to removal? YES�j NO I] <br /> m <br /> b. Identify contractor performing decontamination: <br /> Name r L - <br /> I <br /> Address -Z_15,i_—'Ef_W-V-_ idl y ID_ City �^.11�a,1 v:^5; Zip- F'o <br /> Phone No. °--;%p 21 �" <br /> C. Describe method to be used for decoutaminatiou: <br /> w\i 1`l 'Tti:lt�vtl� Gf t>1CA!w7� t�u - �1 �i} �c =tz �- kr <br /> 1i 1� .SC 1CaGt t j _ R-AALl!)T�_ izL.ii.lr C_� <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offslte: <br /> ��«. iCl tirwi vtY � 11 ir2 is +L � .ti l` fir r� ►nA' <br /> e. Rlnsate Hauler and permitted Treatment,Storage&Disposal Faclllty <br /> 141,1er Name ll G 4 `r ally. c P Hauler Reglstration f ­-AC�6u9 `�,2_4A>1, <br /> Address_ City t. "riw ! kL, ZlpSA ;� )a"za <br /> Phone No.( 6.4 t5Q f';' <br /> Permitted Disposal Site <br /> EH 23 046 (Revised 08113199) page 4 <br />