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RE <br /> SA p [ =J O A Q U I [t [ Environmental Health Department <br /> — [COUNTY- FEES 07 20P(d <br /> ENVIRONMENTAL { EAL H <br /> 1 . (a) Is the current certificate ofworker's compensation insurapcbf�et? �.t1~.N� YES [5 NO [ ] <br /> (b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES b4 NO I ] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work on YES bf NO [ ) <br /> hazardous waste sites in accordance with CCR Title 87 <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [ ] NOW <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit'? <br /> N/A [ ] YESJA NO ( ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAtA YES [ ] NO [ ] <br /> 8. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [X <br /> 6. if tank residual exists, identify transporting ha rdouswa�auler <br /> Name fiCO ii;'l �� ✓� :A <br /> Vtfabier <br /> V1Registration # 1151�� .,` <br /> Address - �OL*yyr ClM XLt�'ittvZAL•4 �✓ 1 <br /> Phone # ((i( ) <br /> 7, Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated priorto remover? YES ( I NO <br /> b, identify contractor performing deco�.Ijtamins n� <br /> Name L '�.3Y 'v"1Jfl� <br /> Address ,_• r)� N . 7'��19C city t-'^I r�.1 .. <br /> Phone No. <br /> c. Describe method to be used f„gyaeconn m nation: <br /> d. Describe how rips@tg i terial will be stored onsite prior to manifesting offsite: <br /> r 1k <br /> e. Rinsale Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name N // Hauler Registration # <br /> Address CityZip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> 8. a. Describe the r�etbod her.01 bg u,Nlized to purge and/or inert the tank(s): <br /> b. Tank/Piping Ha ler. <br /> Name Jt%CE3�� �\ "�1• -�Jt�>3 � 1fiMC�i� (� �j <br /> Address ~ a •1 / • Ciry, ` ! (Zf v � <br /> Phone No.( ) <br /> Hauler Registration # (if hauled as hazardous) y\ <br /> 4 o 10 <br />