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0 W <br />1. (a) Is the current certificate of workers compensation insurance on file? YE _s�'qJ NO [ ] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? YE jrj NO I 1 <br />(c) Has everyone on site, including crana/backhoe operator, been certified to work on ✓v/'` <br />hazardous waste sites in accordance with CCR Title a? YES, t NO [ ) <br />2. Has a "Site Health & Safety Plan' for this job site been submitted? YE$�NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"Tri <br />NIR W YES [ j NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? N�J<YES[ j NO[ ] <br />5. Is there knowledge or evidences of leakage from the tank(s) and/or piping? (If yes, please explain) YES [) NC <br />6. If tank residual exists, identify transponfing h zardous waste hauler. <br />Name i (�//li¢�t/ c�--f-1��4 Hauler Registration # T <br />Address ��� aDX 3-/9 Clty_[EL/y _Zip 9%3 /S <br />Phone # ( ���_ L� �'��j SL, j <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YE $,{ NO[] <br />b. Identify contractor performing decontamination: <br />Name (nI� '7— Ze <br />/N0S210-57 e L�t)G <br />// �, <br />Address __ pio 3�� <3 city o ( Zip <br />Phone No.( J G% )_ �-�L 9 <br />C. <br />Uesonb7, how rite material Will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and Permitted TreatjnenStorage & Disposal Facility: cL <br />Hauler Name�d C Z Hauler Registration #_ .3% _!4 <br />Address P© -0 City—ZIP <br />v�/SG�a//U�cy�i✓V/i2tl-L'/r!F-rJ%�C/l/ a�S�F TE?F <br />Permitted Disposal Site v <br />8. a. Descrih@ the Uthod that will be utiG3ed to pyrgg anrl(or inert the tankfsh. <br />Tank/Piping Hauler. <br />11 <br />a/s D <br />Phone <br />city C', zip �i S'ot 'Y1 <br />Hauler Registration # Cif hauled as hazardous)J X7q Sir i�?o I)— �j3 �/rj' <br />/'4u4£/( A-/ 715- car) 9e -A 5-13 f,?3 <br />EH 23 046 (Revised 8/1/11) 4 <br />