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SAN .(Ih1N . I O n Q U I N Environmental Health Department <br /> — COUNTY— <br /> i . (a) Is the current certificate ofworkees compensation Insurance on file? YES* NO [ ] <br /> (b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES tq NO ( ] <br /> (c) Has everyone on site, Including crane/backhoe operator, been cert lied to work on YES Or NO [ ) <br /> hazardous waste sties In accordance with CCR Title 8? <br /> 2. Has a "Site Health & Safety plan" for this job elle been submllled? YESV NO [] <br /> 3. Has applicant pe orming removal In the City of Tracy obtain (, "Gradlpg�� Excavation Permit•'? <br /> N/Ap YES' NO [ ] IfYE5, PermitiR CC77((,,FF�� <br /> it <br /> J4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA,*YES [ ] NO} i <br /> f Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I ] NOAi <br /> lv/ P- <br /> 6. If tank residual exlsts enlifyt portinah,,,�zaniou wastehauler. G Z�I-`Z� <br /> @ <br /> Name Y � �� Z "'inn ha Hauler Registration It <br /> Address 4 ©r7j`�")�' C <br /> Phone A L � �Z `L c <br /> 7. Decontamination Procedures: <br /> a. Will lank(s) and piping he decontaminated priorto removal? YER" NO <br /> b. Identify con�ga//cperforming deconlaminatlon: <br /> Name <br /> Address "v'•l City - �� ��rW .�—IL�"� <br /> Phone No. Z <br /> c. Describe in lobe usetwaleco 1 min <br /> 1 ' n Y � wtS <br /> r <br /> d. Describe ow rf sale material ' I e t lte te6o toolf <br /> esiin otfsit <br /> i a .WM 220 <br /> :-� <br /> e. Rlnsale Hauler arm] t d realprgAI, a a e & D p F cilily: y; <br /> Hauler Name RSL* a strationig.A L: v <br /> Address P ' <br /> Phone No. ( <br /> F <br /> Permitted <br /> A <br /> Ilted Disposal <br /> �i <br /> 8. a. Describe the me that a zed o ur a nd/ Inert 1n (9)111, <br /> )KNev <br /> •L <br /> T <br /> ct <br /> a <br /> d t o G2/t <br /> b. TankiPipin^g Hauler! <br /> Name (T,Lr'� �Ol CP.V� j 4 " <br /> Address "G City, � � •`-ZtP` �Z <br /> Phone No, �1�7� 1 �7"mZ' {•� <br /> Hauler <br /> �Rlegistration # (if hauled hazardous) <br /> (�e,� <br /> i <br />