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i <br /> I. (a) Is there a PHS-r HD contrnctor's questionnaire on file or enclosed? YES ( j `;O (� " <br /> (bi Is :he current certificnte of wO rker's compensation insurance on :lie? YES ( j NO <br /> (c, Does the contractor possess a "11=rdous Subs=nce Removai Ctrflc=don"" YT" z f .c <br /> (d) Has ever^:one on site. including crane:bacfthoe operator, been certified <br /> co work; on hazardous waste site in accordance with CCR Title S? YES NO <br /> _. Has a "Site Health & Safely Pian" for this job site been submitted? YES (►.jam NO [ j <br /> Has aoolicnnt performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> VA'F � YES ( j NO [ j If YES. Permit <br /> 4. Has the contractor obtained approval from :he focal fire department to perform rani: cutting? NA <br /> XJ YESI j NOf <br /> 4. Is there knowiedge or evidence of leakage from the tanks) and/or pining? (If yes. piease explain) YES r j YO Xf <br /> 6. If rank residuai exists. identify transporting hazardous waste hauler: <br /> `arae-/71C4� rt Hauler Registration _5?`7 <br /> .� <br /> Address : ,' Zip r �• <br /> Ph one ( _/ <br /> Decontamination Procedures: <br /> a. WiII tank(s) and piping be decontaminated prior to removal? YES (�( NO ( j <br /> b. Identify contractor performing decontamination: <br /> It <br /> Name 7, , _a1, <br /> Address - 7F; OAA/> ?/h/- L �,1 �.i� City All;."_/I /=. !) Zip Y7L� J <br /> Phone No.f <br /> C. Describe method to be used for deco lamination: — /j�`�` /,/ 1�< <br /> L c— <br /> z)/ /-/ , e YTi-�� eke/',-�•� <br /> Jig V/.f= 1 r�/Y�/.'�G7 b✓/ ]!C- �d)5' �//�+/ / '� /lFi� /(/'/ �/r�/ l /r S'/ �,•+/�� <br /> f• y <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> I i��i�'H— f—� /T �//y'r-,'/=1TG�=• /t'/.+lr'� /.c7•/ i-f1� f7�����/) l/b' /�/i-rt/���/_C� <br /> e. Rinsate Hauler and <br /> ff permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name ��yi}j /r,1VL66LdZFIEN4 13aaler Registration ;# <br /> Address f : �'7' City //.�-� �7�� <br /> l'/l'% Zip—Q�_63 L7 <br /> Phone No. cs�i�} `79"-7g'41 <br /> Permitted Disposal Site j <br /> Si20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />