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Environmental Health Department <br />r ) i j f%�J T `l <br />1. (a) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES <br />(c) Has everyone on site, including crane/backhoe operator, been certified to work on YES4A j NO[ ] <br />hazardous waste sites in accordance with CCR Title 8? <br />2. Mas a "Site Health at Safety Plan" for this job site been submitted? YES M NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/AM YES [I NO [I If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAX YES [ ] NO [ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NOV <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name r r rdi J 111 ael �%A)7fi' Hauler Registration # <br />Address (/ 130 c 3 90 City ~ri` / Zip <br />Phone # ( �9 ) 1 16 <br />7. Decontamination Procedures: <br />a. Will tanks) and piping be decontaminated prior to removal? YE� NO [ ] <br />b. Identify contractor performing decontamination: <br />Name jll;e 1a.*e?,r dqlc di%1/(i• <br />Address �® City Zip C105 MOO 2 <br />T <br />Phone No.( <br />c. Describe method to be used. for <br />d. <br />e. <br />Describe how rinsate aterial will be stored onsite prior to manifes ing offsite: <br />Rinsate Hauler and permitted4 Treatment, Storage & Disposal Facility: <br />Hauler <br />Hauler Registration # J <br />Address3/�/� � �/�✓ City Zip 5 ? <br />`J <br />Phone No. (7 Q )1(O,f7 7' �D i 7 <br />Permitted Disposal Site 1�A %DJWA �3oU g5AXa2t-1w/ Cf%✓f'V/ dl) WeWi _ 9 <br />� <br />L <br />b. Tank/Piping Hauler: <br />Name <br />Phone No. <br />Hauler Registration # (if hauled as <br />F pOo k%Z� 0 Z <br />tht <br />to pine and/or ink the t�k(s):_ <br />r <br />4of10 <br />City Zip 7 <br />