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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO [ [ <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ ] <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 [ ] <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES NO [ [ <br /> 3. Hascant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/Aap s� YES [ ] NO [ [ If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ J YES[ [ NOK <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES ( ] NO <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name QvV c'-C�\C��91.y� `` Hauler Registration # <br /> Address aq �� �`t�nnv�(] � Ula City!�,\jec- Zip U 4aq <br /> Phone # 02( O�) 1�04a - S%00 '7Q1-`7.Si�� (oyoc <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ J <br /> b. Identify contractor performing decontamination: <br /> Name ly n�'� F,v�.v�A-Oy\n ey.Li..k — <br /> Address (o �. �_ [6 Se City Zip <br /> Phone No.(aOy ) $3:3-Ln <br /> C. Describe method to be used for decontamination: f <br /> S�ers.w. L`��,ti��� � .'� lt���-Q�' j0`4_S-t'=C' W.S•r\1 ��n.(n4 <br /> d. Describe how rinsate material will be stored` onsite prior to manoffsite:offsite: <br /> P: c <br /> off+ , `cc <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler NameAYv 1�,c`\Qcax� Hailer Registration # 3923 <br /> Address Oq 3fl rTlYlnoVd 10c-�ye. City -,m Zip Ksg4aq <br /> Phone No. ( /Qa ) 060b a- (o c00 <br /> Permitted Disposal Site A-0,e C :g0*tjVDQga-2,ca{(&:j <br /> Sno <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />