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1. (a) Is there a PHS-EHD contractor's questionnairon file r enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <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? <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />3. <br />4. <br />5. <br />YES )4 NO [ ] <br />YES NO [ J <br />YES NO [ I <br />YES 'K NO[ ] <br />YES P< NO [ ] . <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A Pq YES [ J NO [ ] If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAM YES[ J NO[ J <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name R,91M0S QV VI P_OA)r04L Hauler Registration # SSI <br />Address ISIS 5. RIVM RD. City W, 5AC, Zip 957F,11/ <br />Phone # ( q & ) 371- 57+2 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES X NO [ ] <br />b. Identify contractor performing decontamination: <br />Name WkLTOA) t5V&tA)6Z _16L4 <br />Address 84-3 P—I 5K 6 Uel. City W 5AC . Zip '15(ocl1 <br />Phone No.( q I /.o ) 3-)3 — L 1 68 <br />C. Describe method to be used for decontamination: <br />"PLIPLE RIN56 <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />RIN54Te WILL Ivo? BE SToge-D ol) 51TC. BUT WI LL I•iE <br />-re vel rx 0 F:-CT!_V Pan TAn1K5 WAD "SV ck TR2ucK IS " <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name RM W5 Q V16.2 161( r41: Hauler Registration # OS Bg <br />Address 151 S 5. RIVE r—p. City VV. S4 • Zip '75-61 / <br />Phone No -L No-LI J (o ) 371- 5217' <br />Permitted Disposal Site 15-15 -5. ec� VE)e- <br />EH 23 046 (Revised 7/10/96) Page 4 <br />