REMOVAL 1996 - Laserfiche WebLink

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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES P4 NO [ ] (b) Is the current certificate of worker's compensation insurance on file? YES:M NO [ ] (c) Does the contractor possess a "Hazardous Substance Removal Certification"'. YES ['Q, NO [ ] (d) Has everyone on site, including crane/backhoe operator, been certified to work on hazardous waste site in accordance with CCR Title 8? YES jd NO [ ] 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES K NO [ ] 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? N/A,K YES [ ] NO [ ] If YES, Permit # 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAP< YES[ ] NO[ ] 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES j ] NO [ 6. If tank residual exists, identify transporting hazardous waste hauler: Name ERICIZSO,V INC.. Hauler Registration # 0019 Address o2SS y0t+A Z .tRLV J) , City kiC4 rn 0 A D Zip cl L-[SO ] Phone 9 ( I D ) al3S— 13g3 7. Decontamination Procedures: a. Will tank(s) and piping be decontaminated prior to removal? YES jiq NO ( ] b. Identify contractor performing decontamination: Name EFT-KSoN jAX_, Address ,SSS' PARR 13 LLID City iz I GH r►AO A.)r) Zip Phone No.( J 10 ) s-- 1343 C. Describe method to be used for decontamination: k i PL &I Al s E/LAU AIS 0- ,J ERT CrA S C 0 2 Y I C_E ) 3n I b pt-A 0 d. Describe how rinsate material will be stored onsite prior to manifesting offsite: 14r,J0vy-- TALC_ e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name C )ZI C KSDA-) t.t7G• Hauler Registration #QQLq Address SSS r04R►2 ALVQ, City alC,4+M0A)0 Zip gLIS01 Phone No. (_Z) D )�,�, — QQ3 Permitted Disposal Site Sf) M E - EH 23 046 (Revised 7/10/96) Page 4