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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on rile or enclosed? YES [ I (b) Is the current certificate o1 worker's compensation insurance on file? YESrNO 11 (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ I (d) Has everyone on site, Including cranelbackhoe operator, been certified to work on hazardous waste site In accordance with CCR Title 8? YES K'NO [ I 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES WIND [ 1 3. Has applicant performing removal In the City of Tracy obtained a "Grading and Excavation Permit"? NIA [ j YES [ J NO (I 1f YES, Permit M 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAI I YES[,INO(1 5. Is there knowledge or evidence of leakage from the tank(s) andlor piping? (If yes, please explain) YES ( I NO (,I 6. If tank residual exists, Identify transporting hazardous waste hauler. NameA�6,1 i t k, l 1/,gIY Hauler Registration N 4 Address �•� , T� O `%C pry b C �N 1 zip S 3 I S Phonefl O� 3 - 4 Cc 45 7. Decontamination Procedures: a. Will tank(s) and piping be decontaminated prior to removal? YES W NO [ ] b. Identify contractor performing decontamination: Name C -F7 I Address 1-2- 1 C- St (f . 7 city T 6 Zip S 35 I Phone Nol � I I 1� Z `'f - 'i it S 7, C. Describe method to be used for decontamination: I P Prn G 1� 6t M PSE 4AU- d /Eo ° U57a6 ,t ec�o�TH6�US6_ 1nC6-G6-gr, Tri£ I -L v E,j A'L AtJS64 w,- BE Ce.69 WAT6t- . d. Describe how Ansate material will be stored onsite prior to manifesting offsite: l.J r7W e. Rinsate Hauler and permitted Treatment, Storage & Disposal FacHity: Hauler Name A�! ZtCA+J L" Hauler Registration# 3711W Address P. O. 6 Z�-_ .3qo city l)6tL_q L- zip / S3/ - Phone No.( 6j00 1 7 3 2' 4— Permitted Disposal Site cam- tC6 O!L 00/0I'-* _40c. — 1,05' 4AZ to 0" EH 23 046 (Revised 10119198) Page 4