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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES NO ( J <br /> ® (b) Is the current certificate of worker's compensation insurance on GIe? YES NO ( ] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES g NO [ ] <br /> (d) Has everyone on site, including cranelbackhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES pq NO ( J <br /> 2. Has a "Site Health & Safety Pian" for this job site been submitted? YES y NO ( J <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Gr2ding and Excavation Permit"? <br /> N/A YES ( J NO <br /> � If YES, Permit # <br /> Xc� <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES NO[ <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES IxNO i <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name AMERtc.Aa VXLLC-•t Hauler Registration <br /> Address 2q 30 9L599 RP- City lUXLocse_ Zip q S 3 SO <br /> Phone # ( 2 0 ct ) 9 ct 3 - (a 2 ] 04 (800) 73Z-44,45 <br /> 7, DecontaminationProcedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES NO <br /> b. Identify contractor performing decontamination: <br /> 11 <br /> Name 5-�d- t t [ rl- A '- r �,L �E_ <br /> Address r" 11 City Zips <br /> Phone No.(_ <br /> C. Describe method to be used for decontamination: <br /> r� <br /> d. Describe how rinsate material wilt be stored onsite prior to manifesting offsite: <br /> O.H e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name H M 6*i c-t,J Vi4 L i V y Hanlcr Registration rl s 3 <br /> Address 2930 66Ee ?O. ­31DG. /S6 city_7_uALocr_ Zip 95'31'0 <br /> • <br /> Phone No. ( 209 ) q(? 3- 7(o0 / 0,t/Pod) 732-46gS" <br /> Permitted Disposal Site /mcg elGLC-It /; SrLVMK SPR 11Vr1S ,N V <br /> 5R0 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />