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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES [;f NO [ J <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [:[ NO [ J <br /> (c) Does the contractor possess a "Ha"rdous Substance Removal Certification"? YES [$ NO ( 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 NO [ J <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES ( NO ( J <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A X YES [ J NO [ J If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[)d YES[ J NO[ J <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ J NO X <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name Allied Petroleum Hauler Registration # 1158 <br /> Address PO Box 193 City Modesto Zip 95352 <br /> Phone # ( 209 ) 576-8500 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [xJ NO [ J <br /> b. Identify contractor performing decontamination: <br /> Name SEMCO <br /> Address 1217 S. 7th St. City Modesto Zip 95351 <br /> Phone No.( 209 ) 524-9653 <br /> C. Describe method to be used for decontamination: <br /> The tanks & piping will be triple rinsed at 1800 using a low volume, high <br /> pressure washer. The first rinse will include the use of a bio degradable <br /> detergent. The two final rinses will be clean water. <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> The rinsate material will be stored on site in DOP 55 gallon drums with <br /> appropriate labels. <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Allied Petroleum Hauler Registration # 1158 <br /> Address PO Box 193 City Modesto Zip 95352 <br /> Phone No. ( 209 ) 576-8500 <br /> Permitted Disposal Site Americlean - Silver Springs NV <br /> EH 23 046 (Revised 7/10/96) Page 4 <br />