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t (a) Is the current certifica of worker's compensation insurance on file? • YESNO[J <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES 8NO(] <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 F%/JNO[] <br /> 2. Has a'Site Health&Safety Plan"for this job site been submitted? YES aNO[j <br /> ' 3. Has,applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/AI_/I YES[] NO[] If YES, Permit# <br /> ' 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YESONO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO <br /> � <br /> No <br /> ' 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> ' Name u chem ojs p m Hauler Registration#N14 <br /> Address 21Gree0cily�n�� zip no <br /> Phone#(499+98 SIr+ ) <br /> ' 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YESFZ]NO[[ <br /> ' b. Identify contractor performing decontamination: <br /> Name ai chm ,osep9 <br /> ' Address 216r oeUfdiw <br /> City Sen.bx Zip 96119 <br /> PhoneNo.(4oa )+9gszr+ <br /> C. Describe method to be used for decontamination: <br /> 2221MDrkffenNrviN$"CxaMend Wow SNWnn. MWaX4Mpfu W"Wfwlpriorlodn ng <br /> ' d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> TN 4met*IW vNNe d 65 germ DOT wPuna. <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name Mcnem PepocN Heufar Registration#2914 <br /> ' Add ressgi weer G>� city S nX Zip 95119 <br /> Phone No.(448 )49 UU <br /> ' Permitted Disposal Site cken Ne op .uwMu. nen <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> AX CMm'/.iIMbVO YX'V3T Yp'Ma,N INNa4<9!'JRBNIbaeatpM bUW,%[1a]bMIIYMNVip USi IL GpTNW iW,iSX IM U$l wtnpptllCV}y,fVytlarY,A mtl]ObI GI47'Cp <br /> Pll Cram wMi remove aM MPa end WM9TanYed aofda cwronH M.9 V"UST,wNh plmtk ego 6 <br /> b. Tank/Piping Hauler: <br /> ' Name No App - <br /> Address City— ] Z !" - _ I <br /> ' Phone No.( ) -- <br /> Hauler Registration#(if hauled as hazardous) OCT 2 15 Ml <br /> ' SAN JOk<iiiijd cGUnl'! <br /> GIJVinONMEN TAL <br /> EI-123046 (Revised 8�I 1 I) 4 I;EALTH DEIDA}RTNENT <br />