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A*,A� -�-,,Cl <br /> 1. (a) Is the current certificate of workers compensation insurance on file? YESNO[ <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification'? YES NO <br /> (c) Has everyone on site.including crane/backhoe operator,been certified to work on YES[J NO i <br /> hazardous waste sites in accordance with CCR Title S? <br /> Has a"Site Health&Safety Plan"for this job site been submitted? (S`n/ 1 & YESX NO QLU <br /> 3. scant performing removal in the City of Tracy obtained a'Grading and Excavation Permit'? <br /> qW YES(J NO[J If YES. Permit# <br /> Hai titre conaactor Ob#&W approval from the lord&9 department 10 perform tar*CUt§W N$KYES[J NO[ <br /> S.L, Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,Please explain)YES[J NO� <br /> V <br /> U\101q�bz-o 3 <br /> t3. If tank residual exists.identify tra h rdous was"Uws- <br /> Nam uler Registration# <br /> hAlAddress Ci Zip "1 <br /> Phone# CAO ^ �Q l <br /> 7. Decontamination ` Q T J <br /> a_ Will tank(s)and piping be decontaminated prior to removal? YES[] NOX <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address city ZP <br /> Phone No-( ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how ansate material will be stored onsite prior to manifesting offsite: <br /> e Rinsate Hauler and permitted Treatment.Storage&Disposal Facility: <br /> Hauler Name Hauler Registration# <br /> Address city Zi <br /> Phone No.( 1 <br /> Permitted Disposal Site <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> b. Tank/Piping Hauler: <br /> Name <br /> Address City Zip <br /> Phone No.( <br /> Hauler Registration#(if hauled as hazardous) <br /> F.N 23 046 (RcvisA d 10/30/12) 4 <br />