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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES [ J NO [ [ <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [ J NO [ J <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES Od NO [ [ <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES Qq NO [ [ <br /> 2. Has a ,Site Health & Safety Plan" for this job site been submitted? YES [ [ NO [ [ <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A YES [ J NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAP(YES[ I NO( [ <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ I NO <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name F r(ikSon lrie,- Hauler Registration # 6011 <br /> AddressZ55 F�Rrr J51Vd• City t,16�^ond zip 614$61 <br /> Phone # ( 510 ) 235 I'jr1 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YESQQ NO [ I <br /> b. Identify contractor performing decontamination: <br /> Name Erlcksovl lna• <br /> Address 255 pQrr Lrjlv(�. City Rich--0—A zip 14bol <br /> Phone No.( �710 ) Z35 IZj�f''j <br /> C. Describe method to be used for decontamination: <br /> `Iri�lc riflSG C5u �1Zns� <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> V16VQw +rll61f, L(vsnr..,ed;atcl-) <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Cri*6k5On lno. Hauler Registration # Qi 1l <br /> Address 255 Parr E?IVJ— city JZ�J%rv.o�d zip 01-4001 <br /> Phone No. ( f2lCi ) 235 — I')°13 <br /> Permitted Disposal Site er(GkSor+ 1Y�6• RiGhw.onti 6A. <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />