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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO [ J <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES Q NO [ j <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 [ J <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES)4 NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/AX YES [ ] NO If YES, Permit # <br /> 1� <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES9 NO[ <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES NO <br /> vA - i& <br /> 6. If tank residual exists, identifytransportinghazardous waste hauler. <br /> Name AmeitmAN VAL.LC-%f Er4V%i 04tJfN7-AL- Hauler Registration # 0?1?5-3 <br /> Address 2430 CTcc'R Rt7. tBt.Da,l5(p City UP-LOC►c Zip 9 S 3 80 <br /> Phone # ( 2Dcf ) Q9 3 - '7400I ce (800) ?32-` (,qS <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YESA NO <br /> b. Identify contractor performing <br /> decontamination: ,Q f� )� ) 4E\ <br /> Name I"1 i"i UL fi-� HR "" U_ �4 <br /> Address reftesm City Zip <br /> Phone No.( <br /> C. Describe method to be used for decontamination: <br /> i� <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> D OM R�7S i <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name AMC*/C0}n/ 0RL,L.C-y Hauler Registration # a9s"3 <br /> Address 2930 6666 RO. City Zip 953k0 <br /> Phone No. ( 201 ) q? 3- 7601 oR(9Q0) 732-416gy <br /> Permitted Disposal Site AM cR/GLc-4,y; SL[.vm&SPR 1a4 S ,N Y <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />