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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] 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"? YES(j NO[] <br /> (d) Has everyone on site,including crauelbackhoe operator,been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES[] NO[) <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YES)ij NO[) <br /> 3. Has applicant performing removal In the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA 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? Of yes,please explain)YES[) NOX <br /> 6. If tank residual exists,Identify transporting hazardous waste hauler. 4t174 �Q <br /> l <br /> Nam Hauler�� ��f�� Hauler Registration# (� <br /> Address ,!(1 !`() City E /_C% ,-%-vZip <br /> Phone# <br /> 7. Decontamination Procedures: <br /> J� a. Will tank(s)and piping be decontaminated prior to removal? YES O NO[] <br /> i <br /> b. identify contractor performing decontamination: a �,i S ' <br /> Name `✓/'f ! L f��(1 '�Ii7l�r// � <br /> 71 S40 <br /> f <br /> Address -5 73'Ost C-�4f C,&6o -P160 City e,6,VcV rZV 21p 174-�5LU) <br /> Phone No.( <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> N IAI <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> � e <br /> Hauler Name <br /> �} / /�/�'� � lf/ j�js s l y Hauler Regisstttration aP <br /> Address (��< , /f/ City[.-_ ",0',141--2) Zip <br /> Phone No. h7036)- 1615f-73 ,IV <br /> Permitted Disposal Site z;�M j PA-Y k , (A'Lz> A-L- : CA <br /> j EH 23 046 (Revised 08113199) Page 4 <br />