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1. (a) is there a EHD contractors and subcontractor's questionnaire on file or enclosed? YES NO [ j <br />(b) Is the current certificate of worker's compensation insurance on file? YES <br />(e) Does the contractor possess a "Hazardous Substance Removal Certification"? ygg <br />(d) Has everyone on site, including crane/backhoe operator, been certified to work on <br />hazardous waste site in accordance with CCR Title 8? YES ( NO ( J <br />2. Has a "Site Health & Safety Plan" for thisjob site been submitted? MSX NO [ J <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A,k' YES[ ] NO [ J If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAYES[ j NO[] <br />5. Is there knowledge or evidence of leakage from the tanks) and/or piping? (If yes, please explain) YES O NOid <br />6. If tank residual exists, <br />,iidentify <br />transporting hazardous <br />/waste hauler: <br />Name ✓� �C�/��/�(�L&OY5��HaulerRegistration# <br />Address & Q 0�C 3 `fD -City-a% zip <br />Phone # o o _ 3 3� Sr7l e2 <br />7. Decoutamivation Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YESX NO( ] <br />b. Identify contractor performing decontamination: <br />Name._ p/r) //flJ/��L 69/Z lam/- • / , <br />Address /" (2 j Q�3 57 City f/(�� zip <br />Phone No.( > _-o, ) , > z 9 <br />C. Describe method to be used for decontaminatinn- <br />d. <br />Rinsate Hauler and <br />/permitted Treatment, Storage & Disposal Facility: <br />Hauler Name� / 7�R'/``/f /Cd9r�dy� %�i�C( f�e7 Hauler Registration # 3 <br />Address_ ,/, D yJ t?,J`- � / V , 'City 121411 ( zip `1'5-315- <br />Phone <br />1'S 3 1 S <br />Phone No. 00 `� aZ 7Z O <br />Permitted Disposal Site dA/NO S f-✓li%//•�(pr!//,yln/i�9�. fs trl"C i— <br />sCV;w iziVet 12040 c%S�c/f7Jc,V•C 5G,/ <br />J� / .r'��7 0"04 &(::,yaOzfV©0S S -.S6- <br />8, a. Describe the method at will be utilized to purge and/or inert the tank(s): <br />Tank/Piping Hauler: <br />Name <br />EH 23 046 (Revised 12/31/07) d <br />