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i <br /> nesllonnaire on file or nclosed? YES D4 NO <br /> NO ( ) <br /> Is there a P'fl5-El1D contractor's q YES � <br /> (h) is the current certificate of worker's compensation Insurance on (lie? <br /> (r) 11nes the contractor possess a "lls7rrdon.q Snhsf�rnee Removal CertIFICAdon"T YES �Q NO <br /> (d) Ifas evervnne nn site, Incl++ding crane/I+arkhoe operator, biern certified YES � NO <br /> to work on hazardous waste site In accordance with CCR Title $? <br /> Z, <br /> snhmiitedT YES.4 NO <br /> Ilan a ,Site llealth k Safety flan" for this job site been t 1 <br /> 3. ITat anplicant performing removal in the City of Tracy ohtninid a "Grading and l�xarntiee fPenelt" <br /> i N/A YFS)Q NO I ( If YES, Permit # <br /> I . <br /> 11-1.1 the cnntraclnr ohtnined api+rn"I from the local fire department to perform tank cutting? NAJM YES( ( NO( <br /> please explain) YES NO <br /> r S. Is there knowledge or evidence or leakage from the tanks) nn for piping? If yes, ( � <br /> t- f, If t+nk residaal exists, identify transporting hazardous waste hauler: <br /> C Nome l4or'-Cal Waste Oil 13aulet s ltaaler Regislrstioe # 5 <br /> Address P-0- BOX 6115 <br /> r City Denai 4—UL— Zip a5a16 <br /> r Soo 332-8710 <br /> tC 1'l+nnr # (� __, <br /> �` �. i)ctnntanrination 1'rncttinr�: <br /> t No ` 1 <br /> a. Will Innk(.t} and piping be decontaminated prior to re, oval? YES [ <br /> identify contractor performing decontamination: <br /> Mime Jim Thorpe Oil , ltrc. <br /> r r pity Lodi CA Zip 45?_41-035 <br /> nddrels P.O. Dox 3�T <br /> 209 368-6175 <br /> rhone <br /> r ' <br /> :. . c. Describe olethnd In he used for decontamination: <br /> i.'ril�.L , r�)-ttse with hot water and biodegr�deable soap solution. <br /> I <br /> d. llescribe holy rinsate material will be stored onsiterlor to manifesting offsite: <br /> iii.tt^ rte will. he i?tnnlfec! directly from hA tank itlto the waste hauler vehicle <br /> CZr pUffl <br /> e. Rinsale If tiller and permitted 1'rralmertt, Storage & Disposal Facility: <br /> F1la+rler Name ��111e as X16 11safer Regf0mtfon # <br /> Address_ City Zip <br /> Phone No. ( ) <br /> Permitted [?ispnsal Site Refinery Services, P"Iterson CA or other approved facility. <br /> F 5120 <br /> F..I1 2,1 11,16 (Revised 9111/96) rage 4 <br />