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1. (a) Is then a PIIS-EIID contractor's questionnaire on file or enclosed? YES)Q NO ( ( <br /> (b) Is the current certificate of worker's compensation Insurance on Isle? YES NO <br /> (c) Does the contractor possess a "Hazardous Substance Removal CertilicaUOn'7 YES NO <br /> 2. Iles a 'Site Health A Safety Man' for this job site been submitted? YES P( NO ( ) <br /> J. llns applicant performing removal In the City of Tracy obtained a 'Grading and Excavation Permii*? <br /> N/A 0 YFS ( ( NO ( ( If YES, Permit # <br /> 4, Iles the contractor obtained approval from tine local itre department to perform lank culling? NAAYES( ) NO( I <br /> S. Is there knowledge or evidence of leakage from lire lank(s) and/or piping? (If yes, please explain) YES ( ( NO <br /> (�)n m o n I fe)I— nC <br /> 6. If lank residual exists, Identify transporting hazardous waste haulen , <br /> Name Nor-Cal WasLe Oi I haulers Hauler Registration # CAD 9£12417255 <br /> Address P.O. Ilox 645 City Dena L', CA ZIP 95316 <br /> Phone # ( 209 ) 332-8710 <br /> 7. Decoolaminallon Procedoress <br /> s. Will lank(s) and piping be decoulaminated prior to removal? YES NO ( I <br /> b, identify contractor performing decontaminations <br /> Name Jim Thorpe Oil , tic./ DBA Nish-Mart Construction <br /> Address 351 N. Beclunan Rd./ P.O. Box 357 Clly Lodi ,CA ZIP 95241-0357 <br /> Phone No.( 209 ) 462-45111 J'1'0/RMI; Ilaz Mat. hauler # 2667 <br /> C. Describe method o be for decontsminallom <br /> On File al, 4' IS/ 111 <br /> d. Describe how rinsme material will be stored onslle prior to manifesting offsite: <br /> The rinseal.e will be r•enxoyed by Jim "l'horpe Oil, lac, personel and placed in <br /> din\a4- 'I lip, driuns will be LrausoorLed by us Lo our vard at 00'7 Black Diaaand <br /> Way, Lodi, CA to await pick up by a qualified collection company. EPA VAL 000012004 <br /> e. Rlnsele Hauler and permitted Treatment, Storage & Disposal Facllllys <br /> Ilauler Name Same as n 6 Hauler Registration # <br /> Address City Zlp <br /> Phone No. <br /> Permitted Disposal Site Refineries Services PaLLerson, CA or other approved facility. <br /> Page 4 <br />