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" SeP•10. 2004 4:29PM Wr,4.ht Environmental 832-5152 No.4242 P. 4/5 <br />1. (a) Is there a EHD contractor's and sub _ ... C -t r-3 questionnaire on file or enclosed? YES <br />NO ❑ <br />(b) Is the current certficate of workers compensation insurance on file? YES)R NO 0 <br />(c) Does the conbactor possess a "Hazardous Substance Removal CefffiCatiOn'97. M <br />including(d) Has everyone on silo, been certified to work OnY <br />hazardousr accordance rTitle ) <br />NO Elr <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />3. Has applicant performing removal in the City of Tracy obtained a, <br />"Grading and Excavation - W NO <br />If YES, Permit # <br />4. Has the contractor obtained approval frorn the local fire department to <br />5. Is them knowledge or evidence of leakage from ft tank(s) and/or piping? YES El NO <br />(If yes, please explain) <br />6. 9 tank residual wdsts, identify transporting hazardous waste hauler <br />^ t�� 1 M • w <br />a ` <br />PhoneAddress <br />+ <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />: F,-70 <br />Name -W(lg +ir_w 1.9/7)o , <br />Address `io`J.�. 6 city, .1� y <br />Phone �o�>,3, 0i651? <br />c. Describe method to be used for decontamination: <br />�. <br />zip 9 <br />d. Describe how rinsate material will be phor to manif-no is <br />t � <br />e. Rinsate Hauler <br />♦ Pemitted Tmabrient, Storagei Disposal <br />Hauler NameAL�z--fwspvck- Hauler ReWstration. <br />�X <br />r <br />EH 23 046 (Revised 10/1&03) Page 4 <br />W <br />