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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES IH' NO I I <br /> (b) Is the current certificate of worker's compensation insurance on file? YES 1.4— NO I I <br /> (c) Does the contractor possess a Hazardous Substance Removal Certification"? YES I +-- NO I I <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 Ir NO I I <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES I`I 'NO 11 <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A IK YES I I NO t I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting'. NAI" 1'E1JNI I <br /> 5. Is there owledge or evt ence of leakag fro the tank(s and/or p ping? (If yes, please explain) YES > <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> NameCCOLOC1 C0NTRoL- IN0UST-It-IES Hauler Registration # 1533 <br /> Address 255 PARR BL• City RI CHMoND Zip `}'801 <br /> Phone # ( S 1 ° ) 2 35 1393 <br /> Decontamination Procedures: '/ <br /> Will tank(s) and piping be decontaminated prior to removal? YES I�( NO 1 I <br /> b. Identify contractor performing decontamination: <br /> Name JNNS CoNSTR.VCTto// <br /> Address 120o E• $HAW City Gt-oVIS Zip 7U,( <br /> Phone No.( <br /> C. Describe method to be used for decontamination: <br /> 'r/zIPt-E (ZtNSE <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> V 1REc.TLy IN'fo VAe-uuPA -FRucK <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> 6cot-06y CONTRot- INDUS AIC-$ <br /> Hauler Name Hauler Registration # <br /> CA 1I533 <br /> Address `Z I A R(z 6L. City g\C 1�Aa o i,,b Zip 14 0 I <br /> Phone No. ( 1110 ) Z35 ( ,313 <br /> Permitted Disposal Site ECOLOGY GoN fteot- INDVSTAIE S <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />