Laserfiche WebLink
1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />3. <br />U <br />5 <br />YES [*< NO [ ] <br />YES ( NO [ ] <br />YES [� NO [ [ <br />YES[( NO[] <br />YES [i✓r NO [ ] <br />Hasant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />app ' <br />N/A YES [ ] NO [ ] If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA[Y1111yES[ I NO[ <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ [ NO [I/� <br />6. If tank residual exists, identify transporting hazardous waste hauler: �f L <br />Namey) L' aLa�z Hauler Registration # "T -2- <br />Address <br />Address 2- • �� � `e) City ( Zip <br />Phone # - — '710 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [Irl***NO [ ] <br />b. Identify contractor performing decontamination: <br />Name -!S '�Q KLA- -) JV ��� UL ► D A� <br />Address P.O. ?)e.PV,- /a LI) eL Cit �.�� 32 <br />y � Zip <br />Phone No.( 3-2- —,5-0 l Z <br />C. Describe methoA to be used for decontaminaPon:�r .'a R) iu U s L C-' 10 V- I�j47 L o I YOA,,4t "'N' C� 7 eeA-J er <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Haulerand permitted Treatment, Storage & Disposal Facility: <br />Hauler Name ke / Cy i- a 1-- Hauler Registration # 2� Z <br />Address (,� . �� �%'� City ► r Zip <br />Phone No.( "30 ) 3 .3 - 2- /'0 , <br />Permitted Disposal SiteX1gr-L)1k- ; 70 1TLiVI�%>�y�UrZ <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 V. <br />