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MAR 01 '99 14:53 PAlE.05 <br />3-01-1999 2:43PM FROM <br />P.5 <br />1. <br />(a) is Charm a PHS•EHD W tfacror's and subcontracrot's questionnaire on file or enclosed? YES ( J NO (J <br />N/A (X) <br />(b) Is the current certificate of worker's compensation insurance on Me? YES() NO[) <br />N/A (X) <br />(c) Does the contractor possess a "Hazardous Substance Removal Certtflcatlon"7 YES [ ] NO <br />N/A <br />IJ <br />(d) Has everyone on sfte, including cranelbackhoe operator, been certified <br />(X) <br />to work on hazardous waste site In accordance with CCR Tille 8? YES [) NO 1I ]' <br />N/A (X) <br />Z. <br />Has a "Site Health & Safety Plan" for this Job site been submitted? YES() No M <br />3_ <br />Has applicant performing removal In the Qty of Tracy obtained a "Grading and Exmvatlon Permit"7 <br />NIA 0( YES[] NO[] It YES, Permit d <br />4 <br />Has the contraemr obtained approval from the local fire department to perform tank rntting? NA <br />'K YES() NO[ ) <br />S. <br />Is there knowledge or evidence of leakage from the M*s) and/or piping? ([f yes, please explain) YES NO [ ) <br />RELEASE REPORTED WHEN CONCRETE VAULT WAS DISCOVERED. <br />6. <br />If tank residual e=—& Identify tlanspordng hazardous waste hauler <br />N/A Name N/A <br />Hauler Registration M <br />Address City Zip <br />Phone d ( ) <br />7. <br />Decontaminatlon Procedures: <br />N/A <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO[] <br />b. Identify contractor performing decontamination_ <br />N/A Name <br />Address QCY 7Jp <br />Phone No 1 <br />o Describe method to be used for decontamtnarit u; <br />N/A <br />d. Describe how rinsate material will be stored onslta prior to manifesting offsite: <br />N/A <br />e. Rtnsate Hanler and permitted Troatmem, Storage & Disposal Facility: <br />N/A Hauler Name Hauler Registration <br />Address Qty 7dp <br />Phone No. ( <br />Permitted Disposal Site <br />EH 23 096 (Revised 10119198) Page 9 <br />MAR 01 '99 14:53 PAlE.05 <br />