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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[-.r-NO[] <br /> (b) Is the current certificate of worker's compensation insurance on Me? YES"0[] <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES(] NO[] <br /> (d) Has everyone on site,including crane/backhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 87 YES{] NO[] <br /> 2. Has a"Site Health&Safety Plan" for this job site been submitted? YES{] NO(] <br /> 3. Has ap cant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA R YES[] NO[] If YES, Permit X <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAI•flES[]NO[] <br /> 5. Is there knowledge or evidence of leakage from the tanks)and/or piping? (If yes,please explain)YES[J NO[� <br /> 6. if tank residual exists,Identify transporting hazardous waste hauler., <br /> Name Hauler Registration 0 16:_153 <br /> Address yes )OAR-p— VA city 9,% F -+i> ZIPIFY90 / <br /> Phone N(S5 & ) Z3 / 393 <br /> 7. Decontamination Procedures: <br /> a. Will tanks)and piping be decontaminated prior to removal? YES W NO I I <br /> b. Identify contractor performing decontamination <br /> Name G� Co nye <br /> Address 8 g No . U41 old <S'(-_ City srmc(��� Zip <br /> Phone No{ ZoQ ) q(;I/—�� <br /> c. Describe petlrod to be used for decontamination: <br /> NSA' OC4AA4 T ACE4 LIQ ��iR( C�NTH/rVJ�i{(/L�TTl� <br /> d. Describe howWaterial will be stored onsite prior to manifesting offsite: <br /> e. Rtnsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler NameAMi?RicP,,t\/Atrya, IV+?ZL—g�erRegistrationM <br /> AddressF-.D_ ZVO City k Zip lea/S <br /> Phone No. <br /> Permitted DisposalSiteTnv - p8iA,( �r��trc1: dLL,Tttc <br /> 1706 cSo . cScrC, �� 4—¢SS i�tJExtt • V25-0 Z3 <br /> EH 23 046 (Revised 10119198) Page 4 <br /> �+�fi"S6 Z-598'—�77 <br />