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S n Jo A O I I�J IN <br /> Environmental Health Department <br /> F-� COUNTY _ . <br /> 1 . (a) Is the current certificate of worker's compensation insurance on file? YES M NO [ ] <br /> (b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES M NO [ ] <br /> (c) Has everyone on site , including crane/backhoe operator, been certified to work on YES pQ NO [ ] <br /> hazardous waste sites in accordance with CCR Title 8? <br /> 2 . Has a "Site Health & Safety Plan" for this job site been submitted ? YES H NO [ ] <br /> 3 . Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A pQ YES [ ] NO [ ] If YES, Permit # <br /> 4 . Has the contractor obtained approval from the local fire department to perform tank cutting? NAN YES [ ] NO [ J <br /> 5 . Is there knowledge or evidence of leakage from the tank(s) and/or piping? ( If yes , please explain) YES [ ] NO N <br /> 6 . If tank residual exists , identify transporting hazardous waste hauler: <br /> ASBURY ENVIRONMENTAL <br /> Name (DBA - WORLD OIL ENVIRONMENTAL SERVICES) Hauler Registration # CAD028277036 <br /> Address 1300 S . SANTA FE AVE . City COMPTON Zip 90221 <br /> Phone # ( 800 ) 974-4495 <br /> 7. Decontamination Procedures : <br /> a . Will tank(s) and piping be decontaminated prior to removal? YES M NO [ ] <br /> b . Identify contractor performing decontamination: <br /> Name CES - Controlled Environmental Services Inc . <br /> Address 50 Sand Creek Road Suite 330 city Brentwood zip 94513 <br /> Phone No. ( 925 ) 447 - 0491 <br /> c. Describe method to be used for decontamination: <br /> PUMP OUT RESIDUAL TRIPLE RINSE INERT. <br /> d . Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> PUMP TRUCK HAZ LIQUID STORAGE TANK <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name ASBURY ENVIRONMENTAL ) Hauler Registration # rnnrnRg77n-A <br /> Address 1300S . SANTA FE AVE. City COMPTON zip 90221 <br /> Phone No. ( 800 ) 974 -4495 <br /> Permitted Disposal Site BAKERSFIELD TRANSFER INC (BTI)- 1120 E BRUNDAGE LN , BAKERSFIELD CA 93307 <br /> 1T77 7 3535 <br /> 8 . a . Describe the method that will be utilized to purge and/or inert the tank(s): <br /> NITROGEN PURGE <br /> b. Tank/Piping Hauler: <br /> Name CES - Controlled Environmental Services Inc . <br /> Address 50 Sand Creek Road Suite 330 city Brentwood zip 94513 <br /> Phone No. ( 925 ) 447 - 0491 <br /> Hauler Registration # (if hauled as hazardous) TANK WILL BE CERTIFIED AS NON - HAZ <br /> 4of10 <br />