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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES)NO[] (b) Is the current certificate of worker's compensation Insurance on file? YES[] NO[] NI R l (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES V NO[] (d) Has everyone on site,Including crane/backhoe operator,been certified to work on hazardous waste site In accordance with CCR Title 8? YES 1/NO[1 2. Has a"Site Health&Safety Plan" for this Job site been submitted? YES[-(NO[] 3. Has ap hcant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? NIA YES[] NO[1 If YES, Permit# 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAj YES[1 NO[1 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[1 NO M 6. If tank residual exists,identify transporting hazardous waste hauler: Name k t* \ VM.LG ( Hauler Regisstration# Address to t)3 4z.2^ LA , city }E-LM ) �4 zip Phone#11 q�V ) -w,41645 7. Decontamination Procedures: a. Will tank(s)and piping be decontaminated prior to removal? YES M/NO[1 b. Identify contractor performing decontamination: 4— Name WLII&C— 6&r; �`-'"� v�644� l�tl. N q II Address Ibp1+ 030019- ALVEI City Ups�� zip 130' Phone No.0� 9q] %9151 151 C. Describe method to be used for deco tamin tion: m C.L��1 , �'LLo>fD'y.. Ss5'A-P •— �iR.lPl.� (Zl r�lf-fib' d. Describe how rinsate material will be stored onsite prior to manifesting offsite: WILL 8V PU4yWKD ql�4LE a►�lf fir BN �R1 chi Yy e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: Hauler Name A \ev—i Q' - \ V"�( Hauler Registration# 314q Address j6103 R Lftt'1f, City ML41 ) CA l zip S 1 Phone No.( } 1 ,1 S Permitted Disposal Sitet7 U5� S EH 23 046 (Revised 08113199) Page 4