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�. (a) is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO[-K" <br /> (b) is the current certificate of worker's compensation insurance on file? 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 8? YES[4"NO[] <br /> 2. Has a"Site Health&Safety Plan" for this job site been submitted? YES+T'/NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A W YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA]A YES[]NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain)YES[] NO K <br /> -DIF-Sel. zys-nn "AS Mir 54 MM&IED r-4 E6 OPEtA-r'iMA DUE-1-0 L &g&GE �nnet <br /> PRIMASY pipime-o I&3rQ kCarkw&PAZV r C.l-rAIMMWrhSG- <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> NameALLVqAS-MTt71Wq Qg J4rpAEpjk-Uiowt Hauler Registration#fir 0x„!354- qq(a <br /> Address City Sikm M y n a zip 9 5©4ca <br /> Phone#( rto$ ) (a$s'Z395 <br /> 7. Decontamination Procedures: <br /> a. Willem piping be decontaminated prior to removal? P)Ptq(tj pru-r YES jq NO[] <br /> b. Identify contractor performing decontamination: <br /> Name S-T,caCTou S - STI�n og �E9 \RME,JX GO rAPAM Y r an c- <br /> Address ge)g W STAT City -r td zip °1520 5 <br /> Phone No.( 7aq ] A¢- 8333 <br /> c. Describe method to be used for decontamination: <br /> -smQ F41►.t�E <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> 5-r 1> 5 <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name Hauler Registration#C,p .f&,3SQ- 9q <br /> Address ACU. Sox _jSa City SAmMAi 1u4 71p 9 'So4t. <br /> Phone No.( 4oB ) G -7-3 g 5 <br /> Permitted Disposal Site "OM1C„ Vtt ,l�i�1�r KDct_�G[a1ssO�CdnES tt P• <br /> BAST PAt-o ALTA <br /> EH 23 046 (Revised 08113199) Page 4 <br />