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v <br /> 1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES NO[] <br /> (b) Is the current certificate of worker's compensation insurance on Dle? YE$N NO(I <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YE$�] NO[] <br /> (d) Has everyone on site,Including cranelbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 8? YE* NO(] <br /> 2. Has a"Site Health&Safety Plan" for this Job site been submitted? YESX NO j1] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA[] YES[[ NO[] If YES, Permit# <br /> 4. His the contractor obtained approval from the local fire department to perform tank cutting?NA[]YE$F4NO(] <br /> 51 Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain)YES[[ N0 { <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> Name / Ain L Lcr��f�)Mn ,��� Hauler Registration# ��p )0 G��a Oj STj <br /> Address � 7set /���� � �Co CityE zip !35d=1.5 <br /> Phone#(moo ) 3oZ hod Co <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES NO[] <br /> b. Identify contractor performing decontamination: l <br /> Name L d— Lfl� vi R.vr,IYXc.I}Al ] ] <br /> Address C1 city . Tor Yo,, zip C <br /> Phone No4,—r�-D�1 1 113�1 — 0 (00 (P <br /> C. Describe method to be used for decontamination: <br /> d. Describe how r� n� <br /> in�sate material will be stored onsite prior to manifesting offsite: <br /> �� -�l[�c '^" S <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name ,_o p nX� Hauler Registration# <br /> t <br /> Address City 01- Zip <br /> Phone No.( ) <br /> Permitted Disposal Site <br /> EH 23 046 (Revised 08113199) Page 4 <br />