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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 rile? YES NO [ [ <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YESM NO I I <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 pQ NO [ [ <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A P YES I I NO I I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAM YES[ I NO[ I <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I I NO <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name - V\( )ill lHauler Registration # n(> �i <br /> l <br /> Address o1IOO �1 tAW(c(>iA tr t?lz r City Zip �(� - D-- <br /> Phone # t <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES JK NO I I <br /> b. Identify contractor performing decontamination: <br /> Name AnLt�_A�oV\ VL5a rc 6`ej1Pt �� LL< IAf Clcy, <br /> Address �F�i 1�c`�� q� —City &(A(AirtA Zip <br /> Phone No.( S3C> )$79) - S-_34L <br /> C. Desribe method to be used for decontamination: <br /> .1 <br /> 1 <br /> tt3 (Asl e A i. 9n�FR <br /> d. Describe how rinsate material will be stored o site prior to manifest ng offsite: <br /> z — cs i Iz <br /> e. Rinsate Hauler and 1permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name�,ck -y- 1- IlI: rpV1Wto_In.tl4A Hauler Registration ft 001 <br /> Address ri-I 0c) &(. N-IILIppL��nAyci»A qri�'! t City i��oT Zip �U �� <br /> Phone No. ( 3�O ) �T�`o -31pb <br /> Permitted Disposal Site VP.V"O, E-K10 tA)n.5J S_WC SQ, <br /> 5/20 <br /> Ell 23 046 (Revised 9/11/96) Page 4 <br />