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0 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 [+ <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? 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 �")(I C W V d l le u J1y lJ t Hauler Registration #311 <br />hiAddress 1� City Zip <br />Phone # (_:Mo _) 132-41,016 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO [q--- <br />b. Identify contractor performing decontamination: <br />Name1�t `i����IuYJ� <br />Address �9 2 W i WaI(Y) City Zip <br />Phone No.(_;Z 09 ) `1 LC " U �67 <br />C. Describe method to be used for decontamination: <br />KI ns(-- i4i+h rA r C r° n C le, -a n inn aiGe � t.. <br />1-11 <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e 0 c: l t b, <br />1iL Id �!S_- ti i ��— ►�1�(b i c i <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: �{ <br />Hauler Name A-�((�(1(�'�(�[/(�(i2n��j//k' l lC'w lL. i1`� L11 Hauler Registration # ��77 <br />Address EU A ✓yCl �/C City VU Zip /`J3/S <br />Phone No. ( ) �� j z �J q5 nn <br />Permitted Disposal Site \O = ck k -r (Yl 11) . � 'C ,L1xn tillI I�L <br />rait <br />E. , izL4tttS �i n � <br />a. Describe the method that will be u i ize to purge and/or ine e�fank(s): <br />b. Tank/Piping Hauler: <br />Name J)_Qt <br />Address City Zip <br />Phone No.( ) <br />Hauler Registration # (if hauled as hazardous) <br />EH 23 046 (Revised 07/22/10) 4 <br />