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L (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[,f NO[[ <br /> (b) Is the current certificate of worker's compensation Insurance on file? YES[,J� NO([ <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES NO[) <br /> (d) Has everyone on site,including cranelbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 8? YES[,]' NO <br /> 2. Has a "Site Health&Safety Plan"for this Job site been submitted? YES[-r NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA(j YES[[ NO[[ If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA(J'YES[J NO[( <br /> 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain)YES[( NO I[ <br /> 6. If tank residual exists,identify transporting hazardous waste hauler. <br /> Name C-O-Aoq�( a�ha k ,�1 Hauler Reglstmthm# C�`AD�pjB2 ()3o 173 <br /> Address �C��Y�7I..K- iJ1�� City I L ZIp�CJ�J_ <br /> PhoneX( SIO ) //`'"l (D <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES 11 NO[.1 <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address -----City------Zip- <br /> Phone <br /> ityZipPhone No.(_ _) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Riusate Hauler and permitted Treatment, y. <br /> t�ment,Storage&Disposal Facility., <br /> Hauler Name L. ' t Q-6 , jtl- L',9aalerftlstration/0-AD C1192030 17-5 <br /> t5r <br /> Address C✓L5 A C}a.'(Z1l^d, Clt l(�)tl'At':rli'�� ZIP 994&') 1 <br /> Phone No.( StO ) //��"l7© -- /-7� C— I ��1 1( <br /> Permitted Disposal StiedC AL khr ui 1, s �7 XL& T1�L <br /> EH 23 046 (Revised 08113199) Page4l <br />