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1. (a) Is the current certificate of worker's compensation insurance on file? YES`11 NO[I <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES-H 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-'F NO r] <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[] NOA <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES[] NOA <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> Name C3 � IA n..r"cm4 VA IHauler Registration# 3 � <br /> Address & �C��O �c 3 �C� �` �City y Zip <br /> Phone#( `/ ) 1 '��0 CD — --13 0� <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 A A-t!'r CO-n \!A <br /> Address Po f30-c 3 4• City ) zip 9 S t 5 <br /> Phone No.(.]-S-00 <br /> C. Describe method t be used for decontamination: <br /> d. Describe how rinsate material will be stared onsite prior to manifesting offsite: <br /> 1.)r I ) 1�,�, b--o ;'fury --,7'y <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name 'A I'm )f�Y�1j &PJ;:-7 2l Qr L Hauler +Registration# <br /> Address P") � fly( ��} �'j City c -t /7 Y Zip ; <br /> -31 <br /> Phone No.( ) ) <br /> Permitted Disposal Site z)< �Jj x b /�1 �E? � v/ f��► y y Erb; <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 ,�2 L <br /> sL 2 � / �E,� C I/ <br /> Address �+6D 1/Lid 31 cl 9 Cites ��+c Zip C ).� <br /> ---��� <br /> Phone No.( - ocl) ) 9,� " <br /> Hauler Registration#(if hauled as hazardous) I fl/ j_r� nC> . &-Zc� <br /> EH 23 046 (Revised 10/30/12) 4 <br />