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- - -- - ---- -- - RECEIVED <br /> FEB 2 6 2014 <br /> • 1. (a) Is the current certificate of worker's compensation Insurance on file? YESA NO[] <br /> (b)" Does the contractor possess a"Hazardous Substance Remog ENTAL YES X NO[] <br /> (d) Has everyone on site,including crane/backhoe operator,been l� ]� ]TMENT <br /> hazardous waste sites in accordance with CCR Title 81 YES-4 NO[] <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YESX NO(] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A,< YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YES*NO[] <br /> 6. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (if yes,please explain)YES[] NOA <br /> 6. If tank residual exists,identify transporting har. <br /> hazardous waste hauler <br /> Name Wo MSSF-VIUS Hauler Registration#Dr� 13�j12 <br /> Address LAO U t--, M 0Y\c1,VU 1510 City � ,CM Zip 0Z- '8 <br /> Phone#( �910 162. - 4L4;50 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES)K NO[I <br /> b. Identify contractor performing decontamination: <br /> Name nttoWIS 'winYvi 03 <br /> 1 <br /> Address �Ci� E • f ,1 UYu�G�YG� City � �AY� zip,UV"`TS <br /> PhoneNo.(�610 <br /> c. Descd a metho to tre Used for deco tamination: <br /> �-r[�p(� sr`�v1�4 and ria-sols fivt lztnk�- <br /> d. De$�e bgpw rin�sa_Mrial will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> _ Hauler Name t' char T yr yf ty Hauler Registrationtit CAT QftQi ri9l <br /> Address.1-400 C—' M* AV-,-1 -w71t City -i`WYAI'Ko ZIP���g <br /> Phone No. :mo l ✓L 3 ���7'� t� <br /> Permitted Disposal Site nmp ]y]OIr�YC�Q� <br /> a. a. Describe the method that will be uliftto purrgge and/or inert the tank ) <br /> Ititi1 b]AUt 30 (bJ F rAIM IGt i _ I�Ujb 0{/-A wnS- l.�fUii <br /> 1n nYL b/Tt7 r <br /> b. Tank/Piping Hauler; <br /> Name f &Jmh �, �SP�N�11Cst3 <br /> Address U4ft � ZP <br /> • Phone No.(9)iQ )7 <br /> Hauler Registration#(if haded as hazardous) ib T()�l�bl3�i�`�- <br /> �ti� x J Ga1i <br /> EH 23 046 (Revised 10/30112) 4 <br />