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0 <br />(a) Is the current certificate of worker's compensation insurance on file? YES [e NO [ ] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ 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 NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [+-NO [i <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A [T 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 Amo)► 6 '611 I IfV � lJ� l L Hauler Registratio <br />Address City I.W Zip <br />Phone # ( )__132 4b �5 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO [� <br />b. Identify contractor performing decontamination: <br />J_ <br />�, <br />Name l�lX r l,t�%J %0661 <br />66 LC 1� <br />Address q5 � W I Vv U_M Dr. City Qb- Zip Cb6W <br />Phone No.(�) �1 l ) U &N <br />C. Descrilae method to be used for decontami ation: <br />ini+h_ a r r- en P_ Ic x.n i na Genf. <br />d. Describe how rinsate material will be stpred onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name A� e (��iew Vo,11eg bl,,*AL Hauler Registration # �/ 7 <br />Address (1 L.IJ/l �yV City Zip <br />Phone No. (() �J <br />Permitted Disposal Site _\0 C' e Af—Y' (y -;I nf�{{�� �_C� w9c ij� i� tUTI Cell <br />a. Describe the method that will i i eibto ournd/or ineell e enk(s): <br />b. Tank/Piping Hauler: <br />Name f\o� <br />Address City Zip <br />Phone No.( ) <br />Hauler Registration # (if hauled as hazardous) <br />EH 23 046 (Revised 07/22/10) 4 <br />