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S <br /> 1 , <br /> 7 <br /> s - <br /> 1. (a) Is there a PHS-EHD contractor's and subcontractors questionnaire on file or enclosed? YES[t�N0[) <br /> (b) Is the current certificate of worker's compensation Insurance on file? YES VNO[) Reneta C,ef�'• <br /> (c) Does the contractor possess a"Hazardous Substance Removal certification"? YES W NO[[ 5'241'0 3 7'"S'Z3'oq <br /> (d) Has everyone on site,including craneibackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Tide 8? YES VNO(j <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted?(11'1 �t PL&D1 P,pe n9 &610 •S 0() <br /> 3. Has apaUcant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA*"' YES[[ NO[[ If YES, Permit B <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAVnSf[NO[[ <br /> 5. Is there knowledge or evidence of leakage from thes)and/or piping? of yes,please explain)YES NO[j <br /> .5 i� � 1 51 /� O Lt C,� i a,LS <br /> COIA <br /> V [ '0 VVI • 6 <br /> 6. If tank residual exists,identify transporting hazardous waste r. <br /> (®haule <br /> Name of C&n VO,((eq UJGL����gq - ®t I RaularRegistradonO <br /> Address �. X70 3 City k t _ Zip 953/ <br /> Phone do 900 ) :162- <br /> 7. Decontamination Procedures: <br /> !' a. Will tank(s)and piping be decontaminated prior to removal? YES Lar NO[) <br /> I <br /> b. Identify contractor performing decontamination: <br /> Name Ll v0.i C�ff &e® .f'1Wo n 1'Yl l <br /> i p <br /> Address 80 5 k a�-W "• city64cWMIZip 7�� <br /> Phone Nol -oq) L (o HOO GO <br /> C. Describe method to be used for decontamination: <br /> f 1x11 <br /> d. Describe Wig rinsatmaterial be stored opsit prior toW, etl4 offsite:asa <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name i C.-C�Yl VX a? A$k-f HaNer Ro tlon# -37 <br /> 44 <br /> Address 7?, 0' �3 0 y_ ✓ city W, Zip 3 <br /> Phone No.c S O0 <br /> Permitted Disposal Site k.t V a�&A L Oil ZV-a_1 S <br /> fer <br /> EH 23 046 (Revised 08/13199) Page 4 <br />