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, <br /> 1. a Is the current certificate of worker's compensation insurance on file. RECEIVE YES NO <br /> (b) Does the contractor possess a Hazardous Substance Removal Certification"? YES [d NO[] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to woW91 5 2015 <br /> hazardous waste sites in accordance with CCR Title 8? YES 5d NO [] <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? ENVIRONMENT NO [] <br /> 1-jr-a,Tu nFaaaTMEN <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A bd YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[)d YES[] NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES [] NO bd <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[I <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 the tank will be triple-rinsed <br /> using a green cleaning agent such as "Smpl . Green"/ <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> Rinse material will be immediately transferred to a pump truck for disposal. However, if any liquid <br /> has to ramain nn-gitp it will he plarari into DOT-raters lahellerl 55-gallon rinimc <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 /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> 15 lbs of dry ice per 500-gallon 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 -Tank will be transported as Non-Haz. <br /> EH 23 046 (Revised 07/17/14) 4 <br />