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I. (a) Is there a PHS•EHD contractors questionnaire on file or enclosed? YES [INO [ I <br />(b) Is the current certificate of workers compensation Insurance on file? YFS [/ NO I I <br />(c) Does the contractor possess a wHaardow Substance Removal CerdfleationR YES [I)/ NO [ ) <br />2. Has a 'Site Health & Ssdety plan' for this Job site been submitted? YES � NO [ ] <br />3. Has epplleant performing removal In the City or Tracy obtained a 'Grading and F.:oeathm Permit"? <br />N/A •U YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[1eWS[ I NO[ I <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ I NO W <br />6. If tank residual exists, Identify transporting hazardous waste hauler. <br />Name Refinery Services Hauler Registration # <br />Addresd3331 N. Hwy 33 CltyPatterson ZIp 95363 <br />Phone # Q09 8y4-4444 <br />7. Decontsmilmdton Procedures <br />a. Will tank(s) and piping be decontaminated prior to removal? YES V NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Paydirt Excavating Co. Inc. <br />Address 269 Oregon St. <br />City Ripon <br />Zip 95366 <br />Phone No.( 209 ) 599-2347 <br />C. Describe method to be used for decontamination: <br />Tanks will be triple rinsed <br />d. Describe how rinsate material will be stored onslte prior to manifestingoffsite: <br />Rinsate will not be stored onsite. <br />The rinsate wil be <br />pumped <br />directly trom tanks to Vacuum truck <br />an au e away. <br />e. Rlnsate Hauler and perndtW Treatment, Storage <br />& Disposal Facility: <br />Hauler Nofinery Services <br />Hauler Registration # 2591 <br />Address 133331 N. Hwy 33 <br />CNIptterson <br />ZIP 95363 <br />Phone No. ( 209 ) 874-4444 <br />Permitted Disposal Site 133331 N. Rvy 33, <br />Patterson, CA 95363 <br />Page 4 <br />