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1. (a) Is the current certificate of worker's compensation insurance on file? YES-Jr. NO(I <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES)[:J NO j] <br /> (c) Has everyone on site,including crane/backhoe operator,been certified to work on <br /> hazardous waste sites in accordance with CCR Title 8? YES4 NO[] <br /> 2. Has a"Site Health:&Safety Plan"for this job site been submitted? YESA:k NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permlt"? <br /> N/A[4 YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perforrq tanj cutting(]YES[] NO[J <br /> t Al t-oee�s 66-['' 1b7/;UAr <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (if yes,please explain)YES[] NO <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> Name United Pumping Service, Inc. Hauler Registration# 063 <br /> Address 14000 E. Valley Blvd. City Industry Zip 91746 <br /> Phone#t 626 ) 961-9326 <br /> 7: Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES[a NO[] <br /> b. Identify contractor performing decontamination: <br /> Name United Pumping Service, Inc. <br /> Address _ 14000 E. Valley Blvd. City---Industry Zip 9746 <br /> Phone No.( 626 } 961-9326 <br /> C. Describe method to be used for decontamination: Pressure wash—triple rinse utilizing <br /> 40 HR• Haz—woper trained confined space crew pumping into vacuum truck, <br /> franspart rinse Water t-n proper disposal facillty-an--manifest. <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> Vacuum Truck <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name United Pumping Service, Inc. Hauler Registration# 063 <br /> Address 14000 E. Valley Blvd. City Industry Zip 91746 <br /> Phone No.( 626 } 961-9326 <br /> Permitted Disposal Site DeMenno Kerdoon — Compton, CA <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): Carbon dioxide from dry <br /> . ice can be used to inert the atmosphere in the tank to below the <br /> oxygen concentration necessary or combustion. pproxima e y 30lbs. <br /> of dry ice per 100 cubic feet of tank volume is required to reduce <br /> b. Tanks/Piping Hauler: the oxygen to 8% . <br /> Name United Pumping Service, Inc. <br /> Address 14000 E. Valley Blvd. City Industry Zip 91746 <br /> Phone No.( 626 )_ 961-9326 <br /> Hauler Registration#(if hauled as hazardous) 063 <br /> EH 23 046 (Revised 10/30/12) 4 <br />