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1, (a) Is there a PHS-EHD contractor's and subcontractor's Questionnaire on file or enclosed? YES NO [ ] <br /> (h) Is the current certificate of worker's compensation Insurance on file? YES NO [ ] <br /> (c) Does the contractor possess a " Hazardous Substance Removal Cerdfleation"? YES NO [ ] <br /> (d) Has everyone on site, Including cranefbackhoe operator, been certified <br /> to work on hazardous waste site In accordance with CCR Title 87 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 /> NIAIfid YES ( J NO ( J If YES, Permit tt <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ J NO <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES ( J N <br /> 6. If tank residual exists, Identify transporting hazardous waste hauler. <br /> Namek)fc a C R A I Q III6 <br /> IC Hauler Registration M Z�a <br /> Address 4) a d7 /C:� >6 9 City DF IJAr r2 ZIP 95316 <br /> Phone M Z:, h b / — Z <br /> 7. Decontamination Procedures: <br /> a. Will tanks) and piping be decontaminated prior to removal? YES NO ( ] <br /> b. Identify t-contractor performing decontamination: I // ` <br /> Name ,� /dVArs1CQO la- , lv <br /> n ' ro0MFrQT9 ) 11f1C <br /> Address '7 fJ C J N1 , ISO () �f r r City S/ o C r, TO 1 Zip 9 <br /> Phone No4 ZG ] b:7 / 0 f? b <br /> e. Describe method to be used for decontamination / <br /> PRes5., rz l 6St+ ins •6je Qt TAv0 4�rjk, r� Dnrrl ;cTu�Trly <br /> d, Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> R ;r66re wdl hE P rr J oN • r tri TANKS F rlfv f] ma brlE <br /> VAC , :. n I \jc K rVkla tal QJ . <br /> e. Rlnsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name LAI 0 I ) Hauler Registration M zQ4 I <br /> Address Oa QX City f 71p 1 16 <br /> Phone No, ( 1 h p ' <br /> Y 11 I ('� /� us Epq Toy* <br /> Permitted Disposal Site etiStr ;;A1 S( AV;( l ' t � l 0 • Capc 1995Z7c5 <br /> EH 23 09 (Revised 10119198) Page 4 <br />