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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YESK NO[ <br /> (b) Is the current certificate of worker's compensation insurance on file? YES,( NO[] <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YESA NO[J <br /> (d) Has everyone on site,including cranelbackhoe operator,been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YESA NO[] <br /> 2. Has a"Site Health&Safety Plan"for this Job site been submitted? YESA NO(j <br /> 3. Has applicant performing removal In the City of Tracy obtained a"Brading and Excavation Permit"? <br /> N1A,K YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NPAYES[j NO[j <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? Of yes,please explain)YES[J NO, <br /> 6. If taek residual exists,identify transporting hazardous waste hauler. <br /> Name s lr � Hauler Registration } c� <br /> Address City Zip <br /> Phone# <br /> 7. Decontamination Procedures: <br /> a. Will teakei)--"piping be decontaminated prior to rea9vW?.11-V/ t/osv/P YES k NO[J <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address G> / / � r'�c Cih' Zip -!S 3 <br /> Phone No.( <br /> c. Describe method to be used for decontamination <br /> :1 / <br /> ��Le +vii ,lje F��S� rG( 4,A4 ROTtj GVa'feA �iYssure UJGS{E/� Ct rru /du/,1 <br /> Air 7/,c.,1 �'i`//re/ au c�.�r s/✓r�;� GuiA4 <br /> d. Describe how rinsate material will be stared onsite prior to manife ting offsite: <br /> .17 ltl et4 / •0/'u,�.s w% /C 67c S <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name � � -�, ��, �� ,�„�.4 s�/Hauler Registration f a 6 <br /> Address ���l �' le City /) Zip <br /> Phone No. 5( -/o1 Ll l c-— /0// <br /> Permitted Disposal Site <br /> EH 23 046 (Revised 08113199) Page 4 <br />