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ECEIVED <br /> Environmental Health Department <br /> bEP 10 2019 <br /> ENV ! � � ONMENTAL HEALTH <br /> riERMITISERVICES <br /> 1 . (a) Is the current certificate of worker's compensation insurance on file? NO [ ] <br /> (b) Does the contractor possess a "Hazardous Substance Removal Certification`? YES <br /> V NO [ J <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work on YES 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? YESX NO [ ] <br /> & HaNappiicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A Qk 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 [ J NO <br /> 6. If tank residual exists, identify transporting /hazardous waste hauler: <br /> &V C ' 4) 17 ��1e���1� <br /> Name 4 Hauler Regisstration # <br /> Address �� /� �r� ` City G I Zip. <br /> Phone # <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES On NO [IFX <br /> ] <br /> b. Identify contractor performing decontamination: <br /> Name 7r//" <br /> Address )'�� 3 :57 City Com' P ( zip 9 r� <br /> Phone No. ( ) <br /> Q Describe method to be used for decontamination: 77Z It f. ZU S L V/ 71 /3 ! ' <br /> L ��if .Stq Lam_f/ (J.� / i9� t) E9f!; /47` oT s <br /> d . be how rinsate material will be stored onsite p or to manifesti gaff ite: <br /> Too et � 1 00 <br /> a <br /> e. Rinsate Hauler and permitted TreatmentStorage & DFacility. <br /> Disposal Facili <br /> / <br /> Hauler Name 64 �'� f hf 00W 16tY . Hauler Registration # <br /> Address. po 3 City d zip 5 <br /> Phone No. ( � ) ii�3 7` gr <br /> Permitted Disposal Site 'C �/ ©l� ��� • ��� <br /> & a. Describe the Wthod that wi e uti�e top and/or inegtha nk(s 1 0 <br /> kr <br /> b. Tank/Piping Hauler. <br /> Names f/'d r ®1 1 1,7&, a <br /> Address ( ` City = Zip S <br /> Phone No. ( 6 QJP� <br /> Hauler Registration # (if hauled as hazardous) ��` L.L/ s� /J � V / •r' WY <br />