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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES I 1 NO ( J <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO ( [ <br /> (c) Does the contractor possess a "H=r4ous Substance Removal Certificatiou"? YES NO ( J <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 [ J <br /> 2. Has a "Site Health & Safety Phan" for this job site been submitted? YES {Q NO [ j <br /> 3. Has ap licant performing removal in the City of Tracy obtained a "Cradieg and Excavation Permit"? <br /> N/A YES I ( NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAW YES[ J NO[ <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES W NO [ [ <br /> TAtik 1.0 #i ((o 0'4 - NOTtLeO I" t551 TASK wq5 F-T OFysOfysc /dPo.J <br /> (LAk tkr�crror�• <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name k8rAD5eN)/(/�l�rKtN_rAL HaukrRtgistiation # Q �gq <br /> Address_ /s S.l //_ oz /N Ctty l 5 Zip_ <br /> Phone a ( //b <br /> 7. Decontaminatiom Procedures* <br /> A. Will tank(%) and piping be decontaminated prior to removal? YES 0 NO [ <br /> b. Identify contractor performing decontamination: <br /> Name ��/'ar"W S ��y t(1 thJ ftt L�rJTfyl <br /> Address �7q1 j/� `�. lxwef2, ZW Z). City SAC Zip l � bq <br /> I I <br /> Phone No.( I�U/ ) j/- 57y7 <br /> C. Describe method 10 he used for decontamination: <br /> 7'R/PGc K/rJ� <br /> d. De3'SbcC how rinsate material will be stored onsite prior to manifesting offsite: <br /> Vfl TR�ck <br /> e Rinsate Hauler and <br /> Permitted Treatment, Storage & Disposal Facility: !'� <br /> Hauler Name �`✓I„WJ /p/�// ( � Flaoler``R,egistratitm # os-1 <br /> Address._�'I I✓L-7 /�Q.c City �• -'1C Zip TS-0/ <br /> Phone No. <br /> Permitted Disposal Site q <br /> T(b <br /> 5/20 <br /> EH 23 046 (Revised 9/111%) Page 4 <br />