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%W <br />AFP1IVE® <br />v <br />1. (a) Is the current certificate of worker's compensation insurance on file? MAR16 2015 YES NO [ ] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? AYES NO [ j <br />(c) Has everyone on site, including crane/backhoe operator, been certifietY_rwft�f41NMENTNNo p( <br />hazardous waste sites in accordance with CCR Title 8? MQV tf 0 rr++ , " NO [ ] <br />HFA' 7J ry=PARTMPk , <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES' NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation "Permit'? <br />N/ YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] N0� <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />L�1��%Wf�.S/� Hauler Registration #-32 � Z <br />Address ! ©Ucex -3z1a G City z2E& Z Zip <br />Phone#(_q�! <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YESX NO[ ] <br />b. Identify contractor performing decontamination: <br />Name 3_Z�7 Tfo zT� O/( //0,-, <br />Address /,Q /3,o x ,3-5-2 City Zip 9 <—e V <br />Phone No.( 2.0 9 ) -3 6 k - 46�/ 7 : <br />C. Describe method to be used for <br />d. D$scribe how rinsate material will be stored <br />e. Rinsate Hauler and permitted Treatment, Storage <br />& Disposal Facility: <br />Hauler Name Aff_4/c,, t///4&Lei 0 iyz Hauler Registration #3 % `f y <br />Address_ /--16 /-?ex -3 0 City )2E�5 1 Zip <br />Phone No. (,2o2 )) //J6, <br />Permitted Disposal Site !7 X_�- d Ixe IJ 3f o C/i/SiJi7I> <br />7,C);7 z593 4!5/->' e-v�0�-oa/L6oz_ <br />8. a. Describe the method that will be utili;ed to purge and/or inert the tank(s): <br />b. Tank/Piping Hauler: - 170ZV 11,yol e4) 4,,10 p1J./Ao1*rd f%i` <br />Name J //1% 5i�/671i%� f <br />Address l7/7 �kX l City!moitJ Zip <br />Phone <br />Hauler Registration # (if hauled as hazardous)dz�i%% FAM fee !'/fN,7jv� <br />EH 23 046 (Revised 10/30/12) 4 <br />