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1. (a) Is the current certificate of worker's compensation insurance on file? YES`11, NO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES ] NO[] <br /> (c) Has everyone on site,including crane/backhoe operator,been certified to work on <br /> hazardous waste sites in accordance with CCR Title 8? YES NO[] <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YES—$ NOA <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? \\ <br /> N/A[] YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YES[] NQX' <br /> jN <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NOX <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: <br /> Name r+._r�=r�- _ A in.r r�..,I Vy�14V Hauler Registration# 13J 4 'r, <br /> T <br /> Address & 13 O k 3 y'(] Cityr zip / S3 ) <br /> Phone#C ^ <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES,[+ NO[I <br /> b. Identify contractor performing decontamination: <br /> Name Ar^&r( Csn 1/_A <br /> Address PO BO-C Z 4t-n City Z4 zip S l <br /> Phone No.( /-Son) 7:2 3 ,.I— 44-6. 4s <br /> C. Describe method t be used for decontamination: <br /> d. Describe how rin ate material will be stq�gd onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name Aitu r)CA v-N Y �j-� 1!� of I Hauler Registration# <br /> Address PO /�?VN `' City zip 9 <br /> Phone No.(� D i)) `��T 409"_ <br /> Permitted Disposal Site__Z. )K D X 0 /J DRO D C4 u tin Q <br /> B. a. Desa the method that will be utilized to purge and/or inert the tank(s): <br /> 2� <br /> b. Tank/Piping Hauler: <br /> Name rJ G? / G/� 1 <br /> Address_446D fIA:) ' I9f7 A/;C�Cit o(:4- zip 9'/_�S cl J.� <br /> Phone No.(� ) ) I :W"DL O � / <br /> Hauler Registration#(if hauled as hazardous)_]a/// 16.p flan <br /> EH 23 046 (Revised 10/30/12) 4 <br />