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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES [ ] NO ( I <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [ ] NO [ ] <br /> (c) Does the contractor possess a 'hazardous Substance Removal Certification"? YES [ NO [ ] <br /> 2. Has a "Site Health & Safety Plan' for this job site been submitted? YES [✓)' NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit'? <br /> N/A [ ] YES N NO [ ] If YES, Permit # 95-1-+6 <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[k YES[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [� <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name wkcy—� 1 nc . Hauler Registration # OC <br /> Address 2x75 Pf,W 1p3L, city VAl Ill Nh zip <br /> Phone # Jal f� ) <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO 14- <br /> b. Identify contractor performing decontamination: <br /> Name ICON. WILL- t-DT <br /> Address city Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> "D PIQWC W 1- R,J'- Hti Lu NS <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name efZl Hauler Registration # D� <br /> Address 2hS PhRR SL . city Rl CH M oO Zip q 4Ro I <br /> Phone No. ( �l0 (� <br /> Permitted Disposal Site W3C20N f-*VlVUlW]fi1t4 1 RedW�oc4 C74Y 1 Ca <br /> Page 4 <br />