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1. (a) Is the current certificate of worker's compensation insurance on file? YES V NO[j <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"7 YES ✓ NO[j <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? YESnNO[] <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YES - NO[] <br /> 3. Has,alicant performing removal in the CHy of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A)_/I YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YESgNO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO� <br /> No <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> Name Al Chem Dmp.M Hauler Registration#2914 <br /> Address 21 Grnm Oaw City San dose Zip H-9 <br /> Phone#(49 119 5274 ) <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YESFV(]NO[J <br /> b. Identify contractor performing decontamination: <br /> Name Nl Chemkm Dis i <br /> Address 71Grein Oe BlM Cit sendose <br /> y Zip 99H9 <br /> Phone No.(409 49 74 <br /> C. Describe method to be used for decontamination: <br /> Clean Interbr tank wiN sknge Green and Wptx SokNon. Murk DUI W,k d erry soktls a fuer Dda tD tleaNrg <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> T retest'mmeflm Wil be alined within M gapan OOT-led Drums. <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name ApcbemDisjo l Hauler Registration#N14 <br /> Address 71 Gzm1 Oaks City San done Zip 95119 <br /> Phone No.(408 )499.5714 <br /> Permitted Disposal Site a4 Harbors.Mgwite.Utmt <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> ap Clwn"ip ramve ury USTpp,q aM nNW eprvpmetl npretyrypdp,aWElolM imercrtl Ne UST. pp fl,e,nyeyn nprlM USi ytk <br /> Al Chem MIa9a„nwpy aaenut4g x4 ml W p 4ryiu <br /> Mcemeled nodMy Gpimhe UST,wim plek sMsalx <br /> b. Tank/Piping Hauler: <br /> Name NmApPl ble <br /> Address City iJPhone <br /> , <br /> Hauler Registration#(if hauled as hazardous) OCT 2 5 71111 <br /> SAN JOAQUtN COUNTY <br /> EH 23 046 (Revised 8JIII I) ENVIRONMENTAL <br /> 4 HEALTH DEPARTMENT <br />