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YES X No 1. (a) Is there aPHS-EHD contractor's questionnaire on file r enclosed? [ ] (b) Is the current certificate of worker's compensation surance on file? YES X NO ( ] (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ j (d) Has everyone on site, including crane/backhoe operator, been certified to work on hazardous waste site in accordance with CCR Title 8? YES NO [ ] 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES pQ NO [ ] 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? N/A [vf YES [ ] NO [ ] If YES, Permit # N/A 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAYES[ ] NO[ ] INskuC-0CA91C- +$ 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES j) NO 6. If tank residual exists, identify transporting hazardous waste hauler: Name dV D 2 C,91- 0 / A C Hauler RegWration # c2 Address R 0, 6X 6 s/$ City—0 la n a i a zip 7S3 Phone #( 800 7. Decontamination Procedures: a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] b. Identify contractor performing decontamination: C. M Name WO 1+6-y) ;-Z h Cr -i A l_ F i-1 "6-- 2 A C. Address P-0 d x.—In -.'� City t,�2. zip Phone No. 7 /b ) J �" CP Describe method to be used for decontamination: ��='c= # Sc) PsT—S. j 0PF_ - WAV". Describe how rinsate material will be stored onsite prior to manifesting offsite: e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name 1 b /G"'. C A O > -mn G, Hauler tion # o? 4/62 Address PC> OX 6 yS city 0MND12 zip 953!6 Permitted Disposal Site Psto Y s i fie.. ► 1. Zvi C® CP r® h C i h u i _ 5-t- 54n}u G2uk 9 �a EH 23 046 (Revised 7/10/96) Page 4 CAD b 6 J a