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1. (a) Is there a PAS-EBD contractor's questionnaire on File or enclosed? YES NO I I <br /> (b) Is the current certificate of worker's compensation insurance an Ole? YES NO [ I <br /> (c) Does the contractor possess a "filazardom Subaasnom Rmovaif Certlfidtlon"T YES NO 1 1 <br /> (d) Has everyone on site. Including crandUckhoe operator, been certified <br /> to work on hazardous waste site In accordance with CCR Title 37 "YES NO 11 <br /> 2. Has a "Site 9ealth & Safety Pian" for this job site been submitted? YES NO 1 1 <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Ezca"tion Permit"? <br /> NIA YES ( 1 NO I I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local Ore department to perform tank eucting7 NAI I YES[ I SOX <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NOX <br /> 6, if tank residual exists, identify transporting hazardous waste hauler! <br /> Name ff/�W43 tG /!h istA-I �n++r raa./w e:.�w.� _Hauler Regis4atiou # a 3 O <br /> Address Ciry ,c 1q zip 9t/S/6 <br /> Phone <br /> 7. Decontamination Procedures: �[ <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES yC( NO <br /> comI 1 <br /> b. Identify contractor performing decontamination: <br /> C t/ <br /> Name <br /> Address U`JaQ .,.,.,,w. -.., '-moi City �� a __Zip 4C-1 Ca <br /> Phone No �U -A --,3 - 0�>`l C 4q <br /> c Describe method to be used for decontamination: <br /> «nwf^eSys_ir 4-t2laTer A/�S1'cr riv;rl ZZZ.-n 4f SQ1J//.{- <br /> on 04/./ <br /> d. Describe bow rinsate material will be stored onai[e priorlto manifesting offal 1 <br /> �'nlafo W7// �t plif�Bt'>f( /,�re� f rtr �sw lF'eJ M <br /> 7"0 _rfAC <br /> C. Rlnsate Haaler and <br /> per>eitted Treatment, Storage & Disposal Facility- <br /> Hauler Name ` j, Hier I'tgi�stiw k �y3gj <br /> Address _ t_.�—_C ea2 :Y Cry �Az>e�� Z1P y51C7— <br /> Phone No. (.—qQ'7 Ll n pe, bb <br /> Permitted Disposal Site \ <br /> 5120 <br /> EH ::3 p46 (Revised 9/12/96) Page S <br /> 'Cf 3r,ti, `lit-13W1-0i idIPJ,l3 1N9L�JM ST5T£3607T b0=7T 11661/61/lT <br />