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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES P¢. NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES IM NO [ ] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES PQ NO [ ] <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title S? YES [pd NO [ 1 <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? S [ ] NO [� <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A 14 YES [ 1 NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAj% YES[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ I NO QQ <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name F>ellehire Enyironmentzl Hauler Registration # <br /> Address 25422 Trabur-o M.�105-2<011 City L2k-, For-e4 Zip 9ZG56 <br /> Phone # ( 714 ) 450- 1010 <br /> r. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES 1d NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name ManeSS norperahOrl <br /> Address 1101 E. Spring f3tMP City Long 9;-,2rh Zip `JOSS <br /> Phone No.(_ 512 ) 5115 -4555 <br /> C. Describe method to be used for decontamination: <br /> Pi i is drained 1=G k ; tt> the. tanks - t2nk5 will be in ed i rin G <br /> will bs remoegd frorn -Nle, tanks vnd stored in 55 08110n d(uw+5 (t=P2k ly Onsite) <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> Qn--rSte 5ha11 be P124rd M 55 wallah drorvis (labelad ao40rdfrA1X) <br /> ntior -}o m2nif,�'1'inq �� i�� <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name 561156ir& Environmen+al Hauler Registration # Z'L1JJ <br /> Address 25422 -rm6y6o 12,d. 4105-2199 City 40-50re"A zip gZ�30 <br /> Phone No. ( 71+ 1010 <br /> Permitted Disposal Site Uemdrnno kerdaon (,Urrt�c�n� GA '510) 537-7100 <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />