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1. (a) Is the current certificate of worker's compensation insurance on file? S NO[] <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certi ica ion ' r~ NO[] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work gra, O 2 Z 6 NO[] <br /> NO <br /> waste sites in accordance with CCR Title 8? [11 R <br /> 2. Has a"Site Health &Safety Plan" for this job site been submitted? ENVIRONMENT;t NO [] <br /> W.cTun A.. . 4Rc��7 <br /> 3. Hasa plicant performing removal in the City of Tracy obtained a"Grading and'�xcava io� ermit;? <br /> N/AYES[] NO [] If YES, Permit# <br /> 4. Has <br /> 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[] N0 <br /> 6. If tank residual exists, identify transporting hazardous waste hauler; <br /> i Y�fAY 7E- Hauler Registration# .3 <br /> Address j,� � -3'71'46 City0��Z/// Zip <br /> Phone# 8 G (>(� / 7 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES K NO[] <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address City —>`/��/ Zip <br /> Phone No.( (7 G 2 ) 36,5- 612-S <br /> C, Describe met d to be used for de nta"nation: _ <br /> Z lv V / e <br /> d. Dp,,scribe how rinsate material will be stored onsite rior to manifestingoffsite: <br /> 1�0 <br /> L Li ' M <br /> e. Rinsate Hauler and permitted Treatment, Storage &Disposal Facility: <br /> Hauler Name G/r! 'v (t,✓4s 7Z- Hauler Registration# �3 2 2 <br /> Address-J12 �/ Y City 1�f L l� Zip /> 3 <br /> Phone No. Cel 2 " si O �/ <br /> Permitted Disposal Site 0 K I�X0,11 Z-UO (f(TWILA) La/A��� G1. 2S'tl,,'Z 0 <br /> 8. a. escribe the method that will be utilized toura and/or inert thJank s : <br /> c .z c c%<< < ,j g/t �/ — <br /> b. Tank/Piping Hauler: <br /> Name 7/-&U CZ- a/ <br /> Address �,�/ 0/�- S /7 City C,-4)0 zip <br /> Phone No.(26 <br /> 6 � l�� <br /> Hauler Registration#(if hauled as hazardous) acl60/b/) JC- iV 1,-00 <br /> EH 23 046 (Revised 12/10/2015) 4 <br />