Laserfiche WebLink
1. (a) Is the current certificate of worker's compensation insurance on file? YES, NO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES NO[] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work on <br /> hazardous waste sites in accordance with CCR Title 8? YES-W NO[] <br /> 2. Has a"Site Health &Safety Plan"for this job site been submitted? YESJ' NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/AJ< YES[I NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YES[] NO[] In PV0Vq-S <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES[] NO> J <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name I�1`r��( nnky�S "VxVi ces Hauler <br /> Registration# <br /> Address `It/�I� �' �� ��( ���/��Yt� City AaAi(l zip 2 <br /> Phone#( 6 1�23 � � <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES j(( 0[] <br /> b. Identify contractor performing decontamination: <br /> Name 1 <br /> Address goo- r& . po ondYA 1rr✓L�)Iypt City Zip JL5 <br /> 651L-t2) 'L-t? V <br /> C. De cribe method to be used for decontamination: <br /> d. cri a hpy r nsa ate i I w 11 be stored onsite prior to mani sting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage&Di osal Facility: <br /> Hauler Namel\MOMI V `t Hauler Registration# C�AT O 13352 <br /> Address U �7d- city ] Zip/J- ]UZ <br /> Phone No. ( ��h ) ` L4& <br /> Permitted Disposal Site VeM ay) <br /> 8. a. Describe the ethod that will be utilizo purge and/or inert the tank(s): <br /> b. Tank/Piping Hauler: <br /> Name Adams /ous, <br /> YA 61 ci -41 Y(��,I d zip `� <br /> Address /� <br /> Phone No.(2` o �/Z� L4 Lq1 o l�-t- w'N� 2 lr <br /> Hauler Regis tion#(if hauled as hazardous) ok 1 ub <br /> EH 23 046 (Revised 10/30/12) 4 <br />