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1. (a) <br />Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />YES Od <br />NO [ ] <br />(b) <br />Is the current certificate of worker's compensation insurance on file? <br />YES Pq <br />NO [ ] <br />(c) <br />Does the contractor possess a "Hazardous Substance Removal Certification"? <br />YES !j(j <br />NO ( ] <br />(d) <br />Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />YES ( <br />NO ( j <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES N] NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A P, YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA)q YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ J NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name �'! � f' v 'c s-��e` c s� Z� Hauler Registration { 72 <br />Address �l fair L �l City I`1 i Zip i (� <br />Phone # ( vef <br />7. DecontaminationProcedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br />b. Identify contractor performing decontamination: <br />Name "-ya11,o rz�! t? <br />AddressU I-3ec iii Wl kd els City L-00 1 Zip e -T S Z- (I C> <br />Phone No.(7 v `t) qt, Z- q S' 1 <br />C. Describe method to be used for decontamination: <br />24 1e4 -E 2107 1 a /r. <br />d. Descr a how rinsate material will be stored onsite prior to manifesting offsite: <br />/1/i L ! / ssr-R C' i.�� Q Z,IZ,! 1.7 / Z- i �C -/ <br />e. Rinsate Hauler LLand permitted Treatment, Storage & Disposal Facility: <br />Hauler Name _�t.J V?[fidL (�CJ�l1 , , Hauler Registration #c*%9 ;P Z <br />Address' Pe lbox -MI5 City �1:?6&269ja Zip <br />Phone No.( ZD q ) '3 3 2 - f37? i o <br />Permitted Disposal Site -Fie ef &i=� <br />EH 23 046 (Revised 7/10/96) Page 4 <br />