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0 <br />1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including cranelbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />2. <br />3. <br />4. <br />5. <br />Has a "Site Health & Safety Plan" for this job site been submitted? <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA [ ] YES [ ] NO [ ] If YES, Permit # /-)/# <br />YESW NO[] <br />YESPJ' NO [ ) <br />YES[( NO[] <br />YESA NO[) <br />YESg NO[] <br />Has the contractor obtained approval from the local fire department to perform tank cutting? N4YES[ ] NO[ ] <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? Of yes, please explain) YES [ ] NO R` <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name i/�]� (� � — / V/ / ,eci A� M en / Hauler Registration <br />Address f�) /E it City �1 1�1 Zip <br />Phone # ( a(,) () ) 21,Z :Z — I 2 F5 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO[] <br />b. Identify contractor performing decontamination: <br />Name D?DD DD ki =;n2 0 <br />Address U I A)C s-- — City �'>r ro Men •Tt zip <br />Phone No 4o�_� 6 <br />C. Describe method tt�jjbe used for decont ation: n <br />A7A)SC &J /7"Ct /'/PsSc ec GrJ, <br />d. Describe how rinsate material will be stored onsite prior toAnanifesting offsite: <br />tl <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name t <//✓ /� &P_ aa) Li 1h et) Il) M Ek) i� � Hauler Registration # 6�2zl <br />Address 6;0 D City Zip <br />Phone No. g� Q ) 7 / ` —12 )" <br />Permitted Disposal Site Lie je CE 0/ L :_4-_ � . <br />EH 23 046 (Revised 08113199) Page 4 <br />