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I. (a) Is the current certificate of worker's compensation insurance on file? YES D4 NO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES [I NO [] <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? YES jd NO [] <br /> 2. Has a "Site Health&Safety Plan"for this job site been submitted? YES Dd NO [] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A M YES[] NO [] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NADKYES[] NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES [] NO[] <br /> NA <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name American Valley Waste Oil Hauler Registration# 3744 <br /> Address PO Box 340 city Delhi zip 95315 <br /> Phone#(800 ) 732-4645 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES N NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Advanced Geo Environmental, Inc. <br /> Address 837 Shaw Road City Stockton zip 95215 <br /> PhoneNo.(209 ) 467-1006 <br /> C. Describe method to be used for decontamination: <br /> Rinse with cleaning agent - Simple Green <br /> d. Db6T rgallonseUrums witehi�iazarrc�ous nwas` e Wels <br /> e. Riinnsaatte Hauler and permitted Treatment, Storage& Disposal Facility: <br /> Hauler Name American Valley Waste Oil Hauler Registration# 3744 <br /> Address PO Box 340 City Delhi zip95315 <br /> Phone No. ( 800 ) 732-4645 <br /> Permitted Disposal Site Disposal site to be determined based on the analytical <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): results of rinseate <br /> NE)NE - besides rinse with above inethod <br /> b. Tank/Piping Hauler: <br /> Name NA - No piping being removed. <br /> Address City Zip <br /> Phone No.( ) <br /> Hauler Registration#(if hauled as hazardous) <br /> EH 23 046 (Revised 8/1/11) 4 <br />