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1. (a) Is there a PHS-EHD contractor's and subcontractors questionnaire on file or enclosed? YES1 NO(] <br /> (b) Is the current certificate of worker's compensation insurance on Ne? YES NO[] <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES NO[j <br /> (d) Has everyone on site,Including cranelbackhoe 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. Has applicant performing removal In the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA�Q YES I] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAI j YES[j N <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES(j N <br /> S. If tank residual exists,identify transporting hazardous waste haur. <br /> le <br /> Name k,1 ro g C-A I Oil Hauler Registration# e�yl <br /> Address 7p �, A7C;X 7 <br /> L96 City DFNflrP, Zip 1531 (, <br /> Phone#( ZJ� 1--E E -7 66 g 2- <br /> 7. <br /> 7. Decontamination Procedures: <br /> a. Will tani(s)and piping be decontaminated prior to removal? YES NO(] <br /> b. Identify contractor performing decontamination: //�� <br /> Name AdVArV(Qt,) 160oE_n� rot)MEn1TAI 1n( <br /> Address yoo5 /v• till jSnn 1vA I 4City S%oc 7-0(1 Zip 52r� <br /> Phone No4 20 ) (, b 7 / 0 0 b <br /> C. Describe method to be used for decontamination: <br /> NPbSvfe, i ;Asd ins;fie Qr TA:vKs Trp_ DroAina.9 irly /z - >7o. A. <br /> d. Describe how Ansate material will be stored onsite prier to manifesting offsite: <br /> RinsA ie- 1ADI hE Dyn(YO �, of Tr) UKS F�n�e z9 Mo dllE <br /> VA(v,;;n -TA\)C a AI QUI <br /> e. Rinsate Hauler and permitted Treatment Storage&Disposal Facility: <br /> Hauler Name jnR ('01 QI I Hauler Registration# 7Y <br /> Address P 0. QX L V City q Zip 9.531 b <br /> Phone No.( ac� ) bo L t q7 <br /> Permitted Disposal Site t)StriAI SCA\li(e. l_"/ ) Co C(4QC()9952, 0 <br /> EH 23 046 (Revised 10119198) Page 4 <br />