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114MV .�4 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO[] (b) Is the current certificate of worker's compensation insurance on file? YES)4 NO[] (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES K NO[] (d) Has everyone on site,including crane/backhoe operator,been certified to work on hazardous waste site in accordance with CCR Title 8? YES K NO [] 2. Has a"Site Health&Safety Plan"for this job site been submitted? YES K NO[] 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? N/A D4 YES[] NO [] If YES, Permit# 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA)4 YES[] NO[] 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO 6. If tank residual exists,identify transporting hazardous waste hauler: Name 2 A yk 0 S F••t V i W F-Als tL Hauler Registration# C r+L O O o LS&6 0_1' Address /S f S S • ]21 V E2 D - Ciry W• S A�o Zip 9 6 4 Phone# ( I& ) 1 - S y 7. Decontamination Procedures: a. Will tank(s)and piping be decontaminated prior to removal? YES[>4 NO [] b. Identify contractor performing decontamination: Name WPtLEGA (-;_ +G I .tritk-(Lc.r.( c C Address Q•m 6 0 K to 2 i City twto Zip S r 6 9. t Phone No.( 5[G ) 3 '4'3 - /( r--- c. Describe method to be used for decontamination: TRtp« TZw.t &-- d. Describe how rinsate material will be stored onsite prior to manifesting offsite: t40 ow S 1 *r V_ Sn A-{ g n•(t�- -To l/A•c _M0CAL- e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: Hauler Name 7 A4,.() S J&E v,n 4 t4A yrWt OIL Hauler Registration# C f+L o o o S P6 fr f Address / S1 -7 S '2t e'rl la' _ City W. SAc-ry Zip 95 4l Phone No. ( 9 3 f f S-L— Permitted Permitted Disposal Site EH 23 046 (Revised 11/21/06) 4