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1. (a) Is the current certificate of worker's compensation insurance on file? YESNO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YE§K NO[] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work on <br /> hazardous waste sites in accordance with CCR Title 8? YES K NO[] <br /> 2. Hasa"Site Health&Safety Plan"for this job site been submitted? A?rAc Nr&D YES K NO[] <br /> 3. Has appilicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A)( YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA{(]YES[] NO[] <br /> 5. 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 e- C= Hauler Registration#CAD q82-630(13 <br /> Address -I-L6, PARD STC?E r-r City RI C-kMOlva Zip 614X10 ( <br /> Phone#( 516 2 .79- [313 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YESX NO[] <br /> b. Identify contractor performing decontamination: //�� <br /> Name CQc-)HZ W ATrw ti <br /> Address 6• ( o x 2-412-7 City I>IJI,>N C )Ty Zip 9q Sd1 <br /> Phone No.( ✓10 ) -711 - 61 sI <br /> C. Describe method to be used for decontaminatiQn� r <br /> 772(P/-A- 21469 i ( �A�r C4 AVQ 104JO <br /> d. Describe how rinsate material will be stored onsite prior to maVnyesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name CC C,4(ZI.JA T E 1Z Hauler Registration# <br /> Address R-0. (36k 14 0:1 City (SNI of j C TV Zip q,'( <br /> Phone No. ( b ) -11J - (,P-75T <br /> Permitted Disposal SiteCt^��IZI�A`i tZ 2y3U �Me�� OrZ. Sty��R SP2�rv� NY <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): D Q -( r C Ii <br /> b. Tank/Piping Hauler: <br /> Name_ (T/� eL4Sy(Z(; 1/,1 -PLAcC <br /> Address City Zip <br /> Phone No. ) <br /> Hauler Registration#(if hauled as hazardous) <br /> EH 23 046 (Revised 07/22/10) 4 <br />