Laserfiche WebLink
1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES ( ] NO [ J <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [ ] NO [ j <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ j <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8'. 'YES NO [ J <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES bk NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A K YES [ J NO [ ] If YES, Permit R <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cuttinep <br /> g? NA( ] YES[ J NOpq <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES ( J NO <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name L °Rye� ) 1 ( Hauler Registration # <br /> Address 33�co S we r City tt Zip S S <br /> Phone ( 5l ) S —S- <br /> r <br /> 1. 1 Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES ( J NO <br /> b. Identify contractor performing decontamination: <br /> Name AM <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> /V4 <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name A- Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br /> i <br />