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1. (a) Is the current certificate of worker's compensation insurance on file? YES[.4 NO I <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES <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 W NO[] <br /> 2. Has a"Site Health &Safety Plan"for this job site been submitted? YES M- NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A N1- YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAkYES[] NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes, please explain)YES[] NO({f' <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name ,A.% • 2 , \\L Hauler Registration#�r <br /> Address ;� ( 00 , iAwRlr�eNia Sr- City /-gvy,►ToLo Zip 4L'L. <br /> 0 2-' . <br /> Phone#( ? 1 D ) 8gt� - 34OD _ 1 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES[ql NO[] <br /> b. Identify contractor performing decontamination: <br /> NameC iU\� w" 0_Rro T2 AlY+tAkAA C6y�1 7-1,Lke-'ti 0 L/k <br /> Address ?10- L0 A, •7 1 Ip City AlAy-��Zip 2211 0� <br /> Phone No.(S30 ) T--7 4 - lrs 4 4 <br /> C. D�gqscribe method to be used for decontamination: 1 <br /> 1�2.1'__Wa_L it <br /> (�- y,+t SS ikyl-f vJ i�4 y'rYb�it iZ.'K.e l> <br /> d. Dscribe how rinsate material will be stored onsi prior to manifesting offsite: <br /> ` 3c r 7 cd ,TL <br /> r iL 114 X'31- A] 1W UNLICIZ <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: r <br /> Hauler Name --11 L K v N.tYVr40 tVMauler Registration# t�l> <br /> Address1lou �, 4! y�i..�.+ar� City gy1zipCLn2.Z2 <br /> Phone No. ( -9(d ) y 69JDD <br /> Permitted Disposal Site D izlM l✓In%.%3DL%ICA QNA ZMO 14. c,S7, Lcq CO- 44 <br /> 8. a. Describe t methd that will be utilized to purge and/or inert the tank(s): <br /> 25 �S �1rn Ott IyttLtfewc� <br /> YCr rir(1d I urn ���� 7Jw.r..Y '`r,•,w✓ �o TrC+,tea JhWT. <br /> b. Tank/Piping Hauler: <br /> Name ue 1 t C- _�C"T4r a J:Tn_..-k•r' <br /> — <br /> Address ( LZ[ T�£1 .�n 14 tZr- , Cityy:L�. ( IT zip q.5 3S6. <br /> Phone No.( 'Z-OCi_) Cy aYs ^41 R <br /> Hauler Registration#(if hauled as hazardous) &)A <br /> EH 23 046 (Revised 07/22/10) 4 <br />