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1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[q-NO[] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO[] <br /> (c) Does the contractor possess a„Hazardous Substance Removal Certification"? YES[ate NO[] <br /> (d) Has everyone on site,including crane/backhoe operator,been certified to work on <br /> hazardous waste site in accordance with CCR Title 89 YES[i1' NO[] <br /> 2. Has a"Site Health&Safety Plan" for this job site been submitted? YES[o]' NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A W YES [] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[eYES[] NO[] <br /> 5. is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO[tom <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> Name Al <br /> l.&y ,4 Hauler Registration# ©01 5 <br /> Address 7-100 1V �l� Q�� � � City o" Zip ac-L-Lz <br /> Phone#( 110 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES/NO[] <br /> b. Identify contractor performing decontamination: <br /> Name��p�,�Int.. r-r+.n l�t ,t t,n n6zlcd_TYZ�•^�bN <br /> Address o oq :Z 11,C/ City JAA J V iq Zip d <br /> Phone No.( r,,ZC� ) S�7 R ^I¢9 `3 <br /> C. Describe method to be used for decontamynation: <br /> %! iu(n f� 'wdN iy[t1 f¢otrc�aiLlR �vttSs�v<< 19�rsh �l <br /> iib of✓/4✓�_ <br /> d. Describe how rinsate material will be storedonsite prior to manifesting offsite: �i <br /> 1Io S%�✓uGaE; 7'' ,dJatuICtr'll tic' 12LAq J Y PL, <br /> �rg lrk ; n > 2 �)rL �/ � f JLe <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name—A-, i t iiiKw(�V t'✓ov -,Lwb/ L Hauler Registration# 60 1 S� <br /> Address ZLUD FA, Al P-L� Ac, (7>T CityC'-o�� Zip—Io-Lz?- <br /> Phone No.( 54C ) ` � <br /> Permitted Disposal Site p�1Mt<In.11O Is �Rdroov. 7.000 <br /> EH 23 046 (Revised 07/31/08) 4 <br />