Laserfiche WebLink
r <br />1. (a) Is the current certificate of worker's compensation insurance on file? YESK 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)d NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES � NO [ ] <br />3. Hasapplicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIAXP YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAX YES[ ] NO[ ] <br />5. Isere knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO <br />A—VI `0`al ^QfkP . W -%L+-, WeAcQ— Lae <t-0 -1.0 (--a-)M<riaca �PreA _ A -i% e 0 <br />6. If tank residual exists, identify transporting hazardous waste hauler: NIA - <br />Name <br />/A <br />Name / Hauler Registration # <br />Address City Zip <br />7 <br />Phone #( ) <br />Decontamination Procedures: <br />a. Will tank piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: N /A <br />Name <br />Address City, <br />Phone No.( ) <br />C. Describe method to be used for decontamination: N `Ar <br />YES [I NOX <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: NIA - <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: W /A - <br />Hauler Name Hauler Registration # <br />Address City Zip <br />Phone No. ( ) <br />Permitted Disposal Site <br />8. a. Describe the method that will be utilized to purge and/or inert the tank(s): �t 1 <br />b. Tank/Piping Hauler: <br />Name N /� <br />Address City Zip <br />Phone No.( ) <br />Hauler Registration # (if hauled as hazardous) <br />EH 23 046 (Revised 8/1/11) 4 <br />