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SAN10 A Q U I N Environmental Health Department <br /> COUNTY <br /> 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 YES [ X NO [ ] <br /> hazardous waste sites in accordance with CCR Title 8? <br /> 2 . Has a "Site Health & Safety Plan " for this job site been submitted ? YES [A NO [ ] <br /> 3 . Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A N YES [ ] NO [ ] If YES , Permit # <br /> 4 . Has the contractor obtained approval from the local fire department to perform tank cutting ? NA[ ] YES [ ] NO [ ] pending <br /> 5 . Is there knowledge or evidence of leakage from the tank(s) and/or piping ? (If yes , please explain) YES [ ] NO [ )J <br /> 6 . If tank residual exists , identify transporting hazardous waste hauler: <br /> Name Adams Services Inc . Hauler Registration # 3216 - 139075 <br /> Address 406 East Alondra Blvd . City. Gardena Zip 90248 <br /> Phone # ( 310 ) 523 -4430 <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 Same <br /> Address City Zip <br /> Phone No. ( ) <br /> C, Describe method to be used for decontamination: <br /> triple rinse <br /> d . Describe how rinsate material \,rill be stored onsite prior to manifesting offsite : <br /> vac truck <br /> e . Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Same Hauler Registration # <br /> Address City Zip <br /> Phone No . ( ) <br /> Permitted Disposal Site Demenno- Kerdoon <br /> 8 . a . Describe the method that will be utilized to purge and/or inert the tank(s) : <br /> Dry Ice <br /> b . Tank/Piping Hauler: <br /> Name Same <br /> Address City Zip 14 <br /> Phone No. ( ) <br /> Hauler Registration # (if hauled as hazardous) <br /> 4of10 <br />