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L� <br />• <br />1. (a) Is there a PHS-EHD contractor's questionnaire on file or 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? I <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? C q+4&e-A r <br />3 <br />4. <br />5. <br />YES,K NO[ ] <br />YESA NO [ ] <br />YES ,K NO[ ] <br />YES P4 NO [ ] <br />YES X NO [ ] <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A 'K YES [ ] NO [ ] If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAb YES[ ] NO[ ] <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 �F 121-c- 5 Ot i --"-A G , Hauler Registration # O O � 9 <br />Address c2 S S fid/"/' ,g�//d. City /Q%c!J /1� bre d Zip 9.y8 b l <br />Phone # ( 5-/0 ) a 3 s - 13 F3 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [VI NO [ ] <br />b. Identify contractor performing decontamination: <br />Name o = e - C <br />IJ <br />Address X5 A, /— City f�vtSf S n� C , Zip 9,�e<�F/ <br />Phone No.( - ?/K 3 ? a ` / ,e 8 8 <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />/70)0 6e— S74o2cW <br />F20/L 74A 16Q,- <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name F&/ 4,50/7 .Z/iC . Hauler Registration # 00/7 <br />Address c2 SS 20"/Z A9100. City _ Zip %yPid <br />Phone No.( 510 ) c;2 3S " 13 73 <br />Permitted Disposal Site F—\J Cre w tr-y,\ V\ 0 t t2 oV\ M c ►n'u I <br />6880 smite IKVG <br />EH 23 046 (Revised 7/10/96) Page 4 W cw 4r k/ r,. 9 y5 6 o <br />C s la) 4 95' - 9/ yo/ <br />EPA* - CV\D 95559 �L 41/8 <br />