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1 <br /> 1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES P(I NO I I <br /> (b) Is the current certificate of worker's compensation insurance on tile? YES bd NO I I <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES (KI NO I J <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 P(J NO 1 1 <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [KJ NO 1 I <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A Iq YES I J NO I J If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[KI YES[ 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 [}} <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name N/A Hauler Registration # <br /> Address Citv Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and ipin be decontaminated prior to removal? YES (XI NO I I <br /> b. Identify contractor performing decontamination: <br /> Name Stockton Service Station Equipment Company, Inc. <br /> Address 808 North Union Street City Stockton Zip 95205 <br /> Phone No.( 209 ) 464-8333 <br /> C. Describe method to be used for decontamination: <br /> The 10 feet of removed piping will be rinsed <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> The rinsate will be stored in a one gallon fuel container. <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Unknown Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />