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1. (a) Is there a PHS-EHD contractor's and subcontractor's questiounafre on file or enclosed? YES No[ J <br />(b) Is the current certificate of worker's compensation insurance an Ne? YEW NO [ ] <br />(c) Does the contractor possess a "Hazardous substance Removal Certification"? YE NO [ j <br />(d) Has everyone on site, Including crane/backhoe operator, been certlHed <br />to work on hazardous waste site In accordance with CCR Title 8? YESX NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES)k NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIV YES [ j NO [ ] H YES, Permit # <br />4. Hasthe contractor obtained approval from the local fire department to perform tank cutting? NA(ES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain)) •,YES [ ] NX <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name American Valley Waste Oil HaulexlygulerRegistration# 3744 <br />Address P.O. Box 340 City Delhi Zip 95315 <br />Phone#( 800 ) 332-8710 <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES j$ NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Jim Thorpe Oil,Ine. <br />Address P.O. Box 357 City Lodi, Zip 95241-0357 <br />PhoneNo4 209 ) 368-6175 <br />C. Describe method to be used for decontamination: <br />The tank(s) will be triple rinsed with hot soapy water nt the <br />rate of four gallons per minute- All rani rllialc anrd rjn�tp will <br />be removed from the tank. <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />The rinsate will be vacuumed directly from the tank while it is <br />being rinsed by the waste hauler into his truck. 11 no truck is <br />available the material will e stored inseaieU drums on Site. <br />Rituals Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name American Valley Waste Oil 9sulerBsglstration# 3744 <br />Address P.O. Box 340 <br />Phone No. ( 800 1 332-8710 <br />CityDelhi Zip 95315 <br />Permitted Disposal Site Americlean of Silver Springs, Nevada or other <br />approved facility. <br />EH 23 046 (Revised 10/19198) Page 4 <br />