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1. (a) Is the current certificate of worker's compensation insurance on file? YES [ NO [ ] <br />(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? YES [$ NO[] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [A NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A [ ] YES [ ] NO [A If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[� YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ j NO [�9 <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name American Valley Waste Oil Hauler Registration # 3744 <br />Address P. O. Box 340 City Delhi, CA Zip 95315 <br />Phone # ( 800 ) 732-4645 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [A NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Advanced GeoEnvironmental, Inc. <br />Address 837 Shaw Road City Stockton Zip 95215 <br />Phone No.( 209 ) 467-1006 <br />C. Describe method to be used for decontamination: <br />Any nominal liquid in tank will be removed via vacuum truck; then tank will be triple -rinsed using <br />a green cleaning agent, such as "Simple Green". <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />Rinseate will be stored in 55-qallon DOT drums or removed immediately usinq a vacuum truck. <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name American Valley Waste Oil Hauler Registration #3744 <br />Address P. O. Box 340 City Delhi, CA Zip 95315 <br />Phone No.( 800 ) 732-4645 <br />Permitted Disposal Site DK Dixon, 7300 Chevron WAy, Dixon, CA 95620 (EPA CAT080012602) <br />a. Describe the method that will be utilized to purge and/or inert the tank(s): <br />15 lbs of dry ice per 500 -gallons of tank volume will be used to "inert" the UST. <br />b. Tank/Piping Hauler: <br />Name West Coast Equipment <br />Address P. O. Box 2368 City Turlock, CA Zip 95381 <br />Phone No.( 800 ) 441-8544 <br />Hauler Registration # (if hauled as hazardous) N/A <br />EH 23 046 (Revised 8/1/11) 4 <br />