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0 0 <br /> 1. (a) Is the current certificate of worker's compensation insurance on file? YES`�Q NO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES 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? AlrAcRED YES X NO[] <br /> 3. Has applicant 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?N%YES[] NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES[] N09- <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name C— c= Hauler Registration#CAD 382-030(13 <br /> Address I tS 'PARR St(A E VC at R I cuma.-J o Zip 1`f 4,0 � <br /> Phone#( 5'16 2 79 t3413 <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 CC.0HU-),A IM X <br /> Address r� b• Q°K �y o2- city unJloN C 01'Y zip I Y Sd 7 <br /> Phone No.( -711 ' (6-151 <br /> C. Describe method to be used for decontaminate n� <br /> �r PL X IVAJSE IJI �01­ LJAECA, /- MQ SAAR <br /> d. Describe how rinsate material will be stored onsite prior to man esting offsite: <br /> if C 0UM I-gucl< <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name C IL aAtZWAT 15/2 Hauler Registration# f{919 <br /> Address (30k 2-40"j �i city UNI*,Q C /i!'�1zip �{Sd <br /> Phone No. ( (b ) -111- (oZSO <br /> Permitted Disposal SiteC1-r:A1Z J,A`f F I, , 2q.To .ALM6IJ0 0m. SIL V A J1PfZ/1#VW NY <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): D Q�f IC E <br /> b. Tank/Piping Hauler: <br /> Name_ CL.ASU R—F IN -(OLAc-6- <br /> Address City Zip <br /> Phone No.( ) <br /> Hauler Registration#(if hauled as hazardous) <br /> EH 23 046 (Revised 07/22/10) 4 <br />