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SAN10 A Q U I N Environmental Health Department <br /> COUNTY <br /> 1 . (a) Is the current certificate of worker's compensation insurance on file? YES M NO [ ] <br /> (b) Does the contractor possess a " Hazardous Substance Removal Certification" ? YES [x] NO [ j <br /> (c) Has everyone on site , including crane/backhoe operator, been certified to work on YES [x] 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? YES [i NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a " Grading and Excavation Permit"? <br /> N/A W YES [ ] NO [ ] If YES , Permit # <br /> 4 . Has the contractor obtained approval from the local fire department to perform tank cutting ? NA[ ] YES [ ] NO bc] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [xj <br /> 6. If tank residual exists , identify transporting hazardous waste hauler: t G <br /> (game American Integrated Services Hauler Registration # 4523 <br /> Address 1502 E Opp St City Wilmington, CA Zip 90744 <br /> Phone # ( 310 ) 522-1168 <br /> 7 , Decontamination Procedures : <br /> a . Will tank(s) and piping be decontaminated prior to removal? YES [x] NO ( ] <br /> b. Identify contractor performing decontamination : <br /> Name L.C. Services <br /> Address 3887 N. Valentine Ave. City Fresno, CA Zip 93722 <br /> Phone No. ( 559 ) 444-1730 <br /> c. Describe method to be used for decontamination : <br /> Triple rinse with water and Simple Green. <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite : <br /> Placed in Drum/rotes or Vacuum truck rated Haz. <br /> e. Rinsate Hauler and permitted Treatment , Storage & Disposal Facility: <br /> Hauler Name Belshire Environmental Hauler Registration # CAR000183913 <br /> Address 25971 Towne Centre or City Lake Forest, CA Zip 92610 <br /> Phone No. ( 949 ) 460-5200 <br /> Permitted Disposal Site DeMenno Kerdoon EPA# CAT080013352 2000 North Alameda St, Compton, CA <br /> 8. a . Describe the method that will be utilized to purge and/or inert the tank(s) : <br /> Purge back product line with nitrogen. Inert LISTS with Dry Ice after triple rinse is performed <br /> b . Tank/Piping Hauler: <br /> Name west Coast Tanks <br /> Address City Zip <br /> Phone No. ( ) <br /> Hauler Registration # (if hauled as hazardous) EPA Hauler ID CA71231 <br /> Piping: Belshire 25971 Towne Center Dr, <br /> Lake Forest, CA 92610 <br /> 949460-5200 4 of 10 <br /> CAR000183913 <br />