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1. (a) Is the current certificate of workers compensation insurance on file? YES NO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YESK 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? YESX NO[] <br /> 2. Has a"Site Health&Safety Plan"for thisjob site been submitted? YES NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A KYES[] NO If YES, Permit# Sf�f� Q�cbt�/ -�•y. <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YES�NO[] <br /> 5. Is there kedge or evil ce olakage from tank(s)and/or piping? (If yes, please explain)YE$[] O <br /> d Z/ <br /> 6. If tank resdduaZxists i nGfy tCrsporting hazardqus waste hauler: <br /> - t <br /> Ser✓r'ccj' <br /> Name 'yL S Hauler Registration# R <br /> Address CitySKS Z' Ss6ZIF <br /> Phone#( 9�L 1 9g0 �O 333 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YE NO[j f/,• ,I i <br /> b. Identify contractor performing decontamination: <br /> Name Al <br /> Address3/GO Ge%///c11"li Of. oroo City n .CffW)O- Zip IS 75.2 <br /> Phone No.( y'(G ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored opsit rior to manifesting offsite: <br /> Csac lD�Sd} <br /> /g Q O r s fe I ff <br /> e. Rinsate Hauler and permitted Treatment, orage&Disposal Facility: <br /> Hauler Name Hauler Registration# <br /> Address City /V G9- Zip .U� <br /> Phone No. ( <br /> Permitted Disposal Site <br /> 8. a. Describe the method thatS wJIVed to py�rge and/or inert the tank(s): / <br /> ow o /KGs scd - F.'//.�w, r +:.r !o S,! 10r!//ice N+•f(O r).) <br /> c 0 .r or y1jr i a <br /> b. Tank/Piping Hauler: <br /> Name O o4 17 4S <br /> Address 3/60 60 to/ V. //f y�r,Ve �80o City�Cana�.�n�d. Zip 9.S7 KZ <br /> PhoneNo.( 9/G ) 8S,21 -91llf AA// <br /> Hauler Registration#(if hauled as hazardous) /V� <br /> EH 23 046 (Revised 07/17/14) 4 <br />