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1�-o %%Mi <br /> 1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES 1:4 NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [A NO [ ] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"'. YES [A NO [ ] <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site 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 j YES [ [ NO [ ] If YES, Permit #, Ci ry of 4t.nrlti nn R] dg_ Permit <br /> forgradinc' <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting. NA[x[ YES[ [ NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES ( [ NO [x] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name Ivor Cal Oil Hauler Registration # CAD 962417255 <br /> Address—p C . l2cx 64r, City fZip 95-1 h <br /> Phone # ( 209— } 605--8739 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES j NO [ j <br /> b. Identify contractor performing decontamination: <br /> Name Samuel Construction Co. <br /> Address P. O. Box737 City Valley Sprirgfp 95252 <br /> Phone No.(209-93}1-5513 <br /> C. Describe method to be used for decontamination: <br /> Tanks and piping to be triple rinsed with biodegradable soap <br /> solution and hot water. <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> Rinsate will be removed by waste hauler from tanks as tanks and lines <br /> are being rinsed or Stored in labled Crums, ,Sk--cileaonsite un it they <br /> can be picked up by waste nauler. <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Ivor Cal 0 i 1 Harrier Registration # <br /> Address same as above City Zip <br /> Phone No. ( _} <br /> Permitted Disposal Site Industrial Service Oil , 1700 S.Soto,Los Angelas <br /> EH 23 446aro <br /> (Revised 9/11/96) Pace 4 <br /> 5 <br />