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1. (a) Is the current certificate of worker's compensation insurance on file? YES M NO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES M 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 Pq NO[] <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YES I(] NO[] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A D] YES(] NO(] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA($YES[] NO[] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO pg <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name American Valley Waste Hauler Registration# 3744 <br /> Address P.o. Box 357 City Delhi Zip 95315 <br /> Phone#(_800 ) <br /> 332-8710 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES Pq NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Jim Thorpe Oil, Inc <br /> Address P.O. Box 357 City Lodi Zip 95241 <br /> Phone No.( 209 329-5481 <br /> C. Describe method to be used for decontamination: <br /> Triple rinse with biodegradeable soap solution and hot water; lines and pipe done same way <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> Rinsate to be stored in approved hazmat drums and labeled or removed when rinsed <br /> e. Rinsate Hauler and permitted Treatment, Storage&Disposal Facility: <br /> Hauler Name American valley Hauler Registration# 3744 <br /> Address P.O. Box 340 City Delhi Zip 95315 <br /> Phone No. ( 800 ) 332-8710 <br /> Ramos Environmental Service (EPA# CAD044003556) <br /> Permitted Disposal Site 1515 S. River Road, W. Sacramento, CA 95691 (916) 371-5747 <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> Dry Ice 30 lbs per 1000 gallons <br /> b. Tank/Piping Hauler: <br /> Name Jim Thorpe Oil, Inc. <br /> Address P.O. Box 357 City Lodi Zip 95241 <br /> Phone No.( 209 ) 329-5481 <br /> Hauler Registration#(if hauled as hazardous) #1715 CAD982523433 ICC#218541 <br /> Dillard Environmental Services <br /> P.O. Box 357, Byron, CA 94514 <br /> EH 23 046 (Revised 07/22/10) 4 <br />