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1. (a) Is there a 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 [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES rit NO [ ] <br />(d) Has everyone on site,including crane/backhoe operator, been certified to work on <br />hazardous waste site in accordance with CCR Title 8? YES [r)\ 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/AYES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA,&dYES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from,the tank(s) and/or piping? (If yes, please explain) YES [ ] NOX <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />J <br />Name lK'(/J 1 (C4,V//,iyceZile j¢.S'��' Hauler Registration# V Z2%r%- <br />Address / tg CJS i� . 3�City Zip <br />Phone # ( kD r7) `3 3 Z &,ye <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br />b. Identify contractor performing decontamination: <br />Name L-)1--7 &/L <br />Address 35-7 ,t). City GCJZip C1�2 5�0 <br />Phone No.(%Y) 3 L <br />C. <br />Des,5ibe how rinsate material will be stored onsite Prior to manifesting offsite: <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name �L 1114&"1H�auler Registration #���ODO.�L <br />Address City Zip - —3 / S <br />Phone No. () L Cl 1;7 /(' <br />Permitted Disposal Site%%�l%/(i1.✓ <br />S PQ�-� Gf �✓� . d2 vT�reC <br />EH 23 046 (Revised 11/21/06) <br />