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07-22-' 14 14: 44 FROM- T-014 P0003/0012 F-019 <br /> t. la) Is tae current certificate of workers compensation insurance on filo? YES NO(1 <br /> (b) goes the contractor possess a"Hazardous Substance Removal Certlfloation"? YES No t] <br /> (c) Hae everyone on site,including oranelbackhoe operator,been cerdited to work on <br /> hazardous waste sites in secordance with CCR Title 6? YEW No[� <br /> 2. Has a"$Ito Health&Safety Platt"for this job site been s0mitted? YE=S j I NONW <br /> 3- Has apptioant performing removal in the CI€y of'l'racy obtained a"Grading and Excavation Permwl? <br /> N/A[J YESK NO[] If YES, Rennit# G' ! -�� <br /> 4. Hes the contractor obtained approval from the local fire' deportment to pertorm lank cutting?NA[]YE NO[j <br /> 5. is there knowledge or evidence of leakage from the tanks)and/or piping? (Ef yes,please explain)YES NCF <br /> 6. If tank residualexists,°lois ":: Motor Carra.er Permit:#0188448 <br /> 7 h r It '1 "yiiag Ut Ham Transportation Regis5xation #350{ <br /> Name , _ b�w �� !�f"� �._ Hauler Registration fE S <br /> Address rd U{lUSi'i� '1_ City Zip <br /> Phone# <br /> 7. <br /> a. Will tank(s)and piping be decontaminated prior to removal? YErSY NCS[j <br /> b. Identify Contractor performing decontamination: <br /> Name L,,i/-&r s <br /> Address ,-Jl city1'6' G49�Zips .� <br /> Phone Na.L ) <br /> c. 'Describe method to be used for deWn(o natio � /` J� 1v�� jr'�'Ay <br /> c/` 4, � <br /> d. Describe how rinsate material will be stored Haifa prior lemon/€eating offsite; <br /> � - <br /> e. Rinsate Hauler and permltted Treatment,Storage Dispossi Facility: Motor Carrier Permitr#028$44S <br /> Hag Transportation Regist ,on #3500 <br /> HaulerName5 . Hauler Registration#—,L-3 1 z z <br /> Address--V-!2f � . �,� � +L `f x City Zi 9 -57� <br /> Phone No. (.. �3_ � . .6413 <br /> Permitted Disposal <br /> $, a. Describe the method that Will be utilized to purge and/or inert the tank(s): <br /> b. Tank/Piping Hauler: <br /> Name + <br /> Address fN{ Clay G Zip 4 <br /> Phones <br /> Hauler Registration#(if hauled as hazardous) /V r 4,0 t <br /> EEH as 046 (Revised 10130/12) 4 JUL 2 2 20% <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />