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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES r L NO[] <br /> (b) Is the current certlHcate of worker's compensation insurance on ftle? YENO <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YE NO[] <br /> (d) Has everyone on site,Including cranelbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 8? YEV1 NO[] <br /> 2. Has a"Site Health&Safety Plan" for this Job site been submitted? YEV} NO[] <br /> 3. Has applicant performing removal In the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A Fi` YES[] NO(] if YES, Permit# ) <br /> 4. Hasthecontractor obtained approval from the local fire department to perform tank cutting?NA( YES[]NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (if yes,please explain)YES[J Nq <br /> 6. If tank residual exists,Identify transporting hazardous waste hauler. f <br /> Name"I 2/Gl4-d 4!4 4! Ji)4 Z— Hauler Registration# C LODD oZ787� <br /> Address 32 1 t74 -J�D City ZIP-q01-5 <br /> Phone#( ADO [ 33p2s Fs7/0 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YEP(NO[) <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address / c� G C.ity <br /> Zip <br /> Phone Noa z 9 J 3 & k 617 s <br /> G Desc be method to be used for decontamination: <br /> <<r<J C Z2/4f/2—'111 £19 ziSTH l��n -124 <br /> d. Des be how rinsate material-WMul be storod onsite prlar to manifesti�ng offsite: <br /> e. Rinsate Hauler and permitted Treatmentt Storage&lllsposa ,Facility: <br /> Hauler Name v d soler ReggistmtIon# * QD <br /> ��Go t/ City L l/ / ZiP 3/5 <br /> Address—A—)&4 <br /> Phone No.( RD ) `z (ffs 7� Q /// �/ <br /> Permitted Disposal Site��l-616gr A 6- c) r7 .�10 l� 1,J0 A- Slel&IC 01n45/S <br /> EH 23 046 (Revised 10119198) ILIff et d��Pa�d �1' !!AI& <br />