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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[] NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A[] YES[] NO[] 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[] NO[] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name Hauler Registration# <br /> Address City Zip <br /> Phone#( ) <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 <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage& Disposal Facility: <br /> Hauler Name Hauler Registration# <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> b. Tank/Piping Hauler: <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> Hauler Registration#(if hauled as hazardous) <br /> EH 23 046 (Revised 10/30/12) 4 <br />