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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES NO [ ] <br /> • (b) Is the current certificate of worker's compensation insurance on file9 YES [ ] NO (X] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ ] NO [ ] <br /> (d) Has everyone on site, including crane(backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES NO [ J <br /> Z. 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)4 YES [ ] NO [ ] If YES, Permit # <br /> 4 Has the contractor obtained approval from the local fire department to perform tank cutting? NAD4 YES[ J NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NON <br /> 6 If tank residual exists, identify transporting hazardous waste hauler: <br /> l <br /> Name mt.c1s�aVJ1a,, C,4yrVIenws;.cg-,A,, Hauler Registration # <br /> Address 2513a CnQ.R 51f: 151P City L)r lock Zip Gz%o <br /> Phone # ( $oo <br /> 7 Decontamination Procedures: <br /> • a. Will tanks) and piping be decontaminated prior to removal9 YES [ ] NO (� <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address City Zip <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 /> e Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Hauler Registration # <br /> Address City Zip <br /> Phone No. ( <br /> • Permitted Disposal Site <br /> 5/20 <br /> EH 23 046 (Revised 9111196) Page 4 <br />