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1 s s <br /> 1. (a) Is the current certificate of workers compensation insurance on file? YES BNO[] <br /> 1 (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? YESFV]NO[] <br /> ' 2. Has a'Bite Health&Safety plan"for this job site been submitted? YES WINO[] <br /> 3. Has,a licant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/AI_/I YES I] NO[] If YES, Permit# <br /> 4. Has the lcontractor obtained approval from the local fire department to perform tank cutting?NA[]YESaNO[] <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 /> i <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> ' Name unkngwn-Pending Analyses Hauler egistration# <br /> Address City Oakland Zip <br /> ' Phone#( ) <br /> 7. Decontamination Procedures: <br /> 1 a. Will tank(s)and piping be decontaminated prior to removal? YES V NO[] <br /> b. Identify contractor performing decontamination: <br /> 1 Name Ag Chemical Disposal <br /> Address 31 Greal oaks OW City san.lose Zip 95119 <br /> ' Phone No.(409 )4993274 <br /> C. Describe method to be used for decontaminatio . <br /> Cfean inUror link with Sknple Green and Waler$DIU5pl1. Mutll duly larryadlde or Nel prbrhdepning. <br /> 1 Describe how rinsate material will be stor onsite prior to manifesting offsite: J <br /> The Mail-mal-dal will W Shred wIINn 5 gallon DOT rzled ma. <br /> e. Rinsate Hauler and permitted Tre ent, Storage&Disposal Facility: <br /> Hauler Name Unlalown-eendin9Areyea, Hauler Registration# <br /> 1 Address City Zip <br /> Phone No. ( 1 <br /> Permitted Disposal Site <br /> 8. a. Describe the method th will.be utilized to purge and/or inert the tank(s): <br /> ' AIILhemwlll remwou,y VST piping ,el,dd1Ulpmamr.0..n,1ogelnacpae to Nellmold NeUST. IYLtaM wi.Nen lnod 111p UST wIN o,9enkvupor suprvusenl end dry ke. <br /> All CMM will remove any debris coMaminaled Wadi cunenly filling Ne UST,with plpsdc shovels. <br /> b. Tank/Piping Hauls . <br /> 1 Name Nol ApmicaGa <br /> Address City Zip <br /> 1 Phone No <br /> Hauler egistration#(If hauled as hazardous) <br /> 1 <br /> EH 23 046 (Revised 8/I/11) 4 <br /> 1 <br />