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4 Vr <br /> 1. (a) Is the current certificate of worker's compensation insurance on file? YES K 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? YES NO[] <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YESX NO[] <br /> 3. Hasa licant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A YES[] NO If YES, Permit# .Sf�f• Q�abf- <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YESY-No[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YE$�[loo� <br /> lrf060A1 41-r fid ?A/df_lTeYf�arr/ Rfi�4✓zi' i7!// 3 <br /> /YO .fYl�✓/1Gc.�r'T L.sr/�Ac�J — TiF.ri Z;� v _ <br /> 6. If tank iesiua]1exists n ty tr3nsporting hazard us waste hauler: <br /> - ren iY ✓rr•nn�r.,r• Srrur<ef srisF <br /> Name /7�1F7r�LS c, Hauler Registration# /VF?/-s o <br /> Address-100170. ���/ City F Op S zip 9-Sb c.tl <br /> Phone#( 9/4 ) 99D '0333 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YE�-X NO[] <br /> b. Identify contractor performing decontamination: <br /> Name ��YLoit/ C,onsa /,4'.1�fi 1n e <br /> Address?/GD Ge/Vd•/L.� Of. OF40 city/Yand.`ire6r< zip %s 7e. . <br /> Phone No.( fY6 ) RSa -9//E <br /> C. Describe method to be used for decontamination: <br /> RLr�soiis JOcrQ �•vA�i/J pc.9�f .Tyv Tr l�.2ri.�rJ <br /> nay sCdz a-&!5 ;sda= -+X-�p 60rF pct!- 0 e <br /> d. Describe hoyr rinsjto material will be stored onsite pptfor to mam stin offsite: / <br /> �f"ULrj/•�S -d� <br /> Sail_4AAs.r(,4± S2aeeaeA 17374./,4Oranrr a � L;AeA arq 4lYa,)rgl// <br /> O iw .r re •/ I� Ori e� <br /> Jr <br /> e. S•rl/Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name 11'`l�"NRC Hauler Registration# _ 157.i9_ <br /> leos- 4c74 �♦.nY f�/arced. <br /> Address ',d ' Jfi City 14.44 zip Aryly-9Ys0/ <br /> Phone No.t J 1//'r7"rr0) 7V9 -/39 0 <br /> Permitted Disposal Site /61* bleat, /irrar6Or1 ��f{'�nWr//••J L•w�f'/1 <br /> 8. a. Describe the method that will be uized to p rge as cifor inert the tank(s): <br /> TQA �'O $ : ., V OSG - f;�i..'6./. lJ�in-/ a.rQ/.I �.i/�Q/l��i� /�•drry.J <br /> b. Tank/Piping Hauler/: <br /> Name /COI/� rO/)X4 Mf 14S Z/ C <br /> Address 3/Go 6�/d . //e,. 09f: Boy city�4nG{.Cy/,✓. zip 9S7Y-a <br /> Phone No.( 9/4 1 8Sx 4W .w�// <br /> Hauler Registration#(if hauled as hazardous) /V� <br /> EH 23 046 (Revised 07/17/14) 4 <br />