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(] J� A ' i <br /> S A N J O A Q N I N Environmental Health Department <br /> --- COUNTY -- <br /> 1 . (a) Is the current certificate of workers compensation insurance on rile? YES P4 NO [ I <br /> (b) Doe's the contractor possess a "Hazardous Substance Removal Certtticatlon'7 YES M NO [ I y/W eNyndC/larrr.7 r-q.�Y <br /> (c) Has everyone on site, including cranefoackhoe operator, been cer ified to work on YES 0 405* <br /> hazardous waste sites in accordance with CCR Me 8? <br /> 2. Has a "Site Health & Safely Plan" for this Job site been submitted? YES** NO <br /> LI <br /> 3. Hasapplicant performing removal In the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A YES [ ] NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ I YES [ I NOM /IV/X- <br /> 5. Is there knowledge or evidence of leakage from the lank(s) and/or piping? (If yes, pleaseexplain) YES [ I NO <br /> 6. If tank residual exists, identify transporting <br /> hazardous waste hauler. Vr56 x/711 ^ / /� <br /> Name lS2—/ /! ��T ' gfshalfonrie411 eo! ZJ.315�2 <br /> AddressCityrA&AiJ4 E2 rip 9s4 0e) <br /> Phone # ( �/d ) 577 - Z 2 pp <br /> 7, Decontamination Procedures: ArbT <br /> a. Will tank(s) and piping be decontaminated prior to removal? G7o5c/ice YES f ] NO [ j <br /> b. i Identify contractor performing decontamination: <br /> Name /�'i� YL!/ -40 S�/ 2j// CSS <br /> Add reaa /oyin �G <br /> 'fb 5 <br /> M � %? City,/i✓�ro�10�//l& zip -.:z5'4 <br /> Phone No.(931 ) X.Sn 0126 <br /> C. Describe method to b used for decontamination- <br /> :rtf4 ,/ eazr <br /> d. Describe howdnsale material will he stored onsite. prior to manifesting.offsfte: <br /> V& TA /= <br /> e. Rinsale Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name / / T/UT/✓5 Hauler Regfstration #C.q�/ se. <br /> Address ��� $/f-„rJ✓—ff / i�i���— L7 City 1AW01'e zip <br /> 'Phone No. ( S/ bfr� <br /> i � w 7 <br /> Permitted Disposal Site C/�s� /',g0/5 Sq,? TOSQ �%e COL/ <br /> SA-N 0uS � Cgv Pte! 3a <br /> 8. a. Describe the method that vA, be utilized to pyrge and/or inert the hmk(s): <br /> Tex=r7i-r�ri y-ity� ' TiLIO®/E C/.em+.s4✓� s� +°J <br /> b. TanklPiping Hauler. <br /> Name '"' <br /> Address Cdy Zip <br /> Phone No.( 1 <br /> Hauler Registration # (f hauled as hazardous) <br /> 4 of 10 <br />