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Environmental Health Department <br /> SAN ,::JQAQUIN <br /> _COUNTY.._.._. <br /> i <br /> i <br /> 1. (a) is the current certificate of worker's compensation Insurance on file? YES NO[ ] j <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES N N [ I <br /> (c) Has everyone on site,including crane/backhoe operator,been certified to work on YES M NO[ ) I <br /> hazardous waste sites in accordance with CCR Title 8? I <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YES R NO[] <br /> I <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? i <br /> N/A)( YES[) NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[X YES[ ] NO[ ) <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (if yes,please explain) YES[ ) NO)4 I <br /> i <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> NameA��(L2 A f44 ✓.4 4L X41 sig Hauler Registration# / <br /> Address PQ Box -/ .) _City Zip <br /> Phone#(7 O <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES% NO[ ] <br /> b. Identify contractor performing decontamination: <br /> Name 3161 L/ 0IM-2 O/C /61e <br /> Address l�D /3Q�C v j City Zip 5� <br /> Phone No.( 2 0 ) :72- 2— �7 <br /> 74-1)K L/-/) <br /> /4 req i3.= 721 °L S /2)4!S£r) <br /> C. Describe method to be used for decontamination:4//7/,/ /,to Q 7'-'rt AW D 9 1 r2 1�d(;"If'14sa SO4 sae zweiz� <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: G j mis'�' /-I, �/,�/�5����C <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: S744L,11 <br /> Hauler Name/F/��/?Ili�'� ill?l!E OVA s7f'Dll Hauler Registration# / <br /> Address City D �f��Zip / l <br /> Phone No. V ��✓ <br /> �2���. ���--/ `l ,off <br /> Permitted Disposal Site 1� ' ������ 23t�fl G�/fil/�dFV i�r// Uf)(04) �'r • 2� <br /> 8, a. Describe the method that will be utilized to purge and/or Inert the tank(g: <br /> 1A1rX-AVtj2 7alO E C��. S,- all <br /> i <br /> b. Tank)Piping Hauler: <br /> Named Ole <br /> �5 Ot <br /> Address City Zip j <br /> Phone No. <br /> Hauler Registration#(if hauled as hazardous)�(�/�f!/��/� ��^/tl+//jt f��r!►1�.Yn� �� <br /> 4of10 <br />