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1. (a) Is there a PHS-EHD contractor's questionnaireQnrler enciosed? <br />(b) Is the current certificate of worker's compensatrance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <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? <br />2. Has a "Site Health & Safety Pian" for this job site been submitted? <br />3. <br />4. <br />5. <br />6. <br />7. <br />YES M NO [ J <br />YES JM NO ( J <br />YES NO[J <br />ym s <br />YES 'A NO [ J <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A X YES [ J NO ( ( If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAA YES[ J NO[ J <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ( NO <br />If tank residual exists, identify transporting hazardous waste hauler: <br />Name "I M 0 5 1FPvV1Ro"jM A (- Hauler Registration # D S- i 15 <br />Address 1515 S. R t Q t* L- � CityW. SAG Zip q501 <br />01 <br />Phone # (q 1 (;�, ) 32' - s <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />YESK NO [ J <br />b. Identify contractor performing decontamination: <br />Name M.i�\ L. -roti E�J<G <br />Address �� §�js� i �' �` City W �t <br />Zip �� { <br />Phone No. (� (1 M (i~ <br />C. Describe method to be used for decontamination: <br />TP.I PL F R 44V. ' <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />P-1 AJSA ILL /et BE 5--6 XiF-[� CW 5(7 Wi <br />P-1 <br />-rw�v.r n.nrr-ra v caj!im MAtjN .'_S INTI ;1504!- Ta r -K , <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name R14 M ®—QV V(a;4JM 6Ar AC_ Hauler Registration # OSf -5 <br />Address I5 f S 5, Ri VE(L. R -D , City 5-4 C- Zip <br />Phone No. ( 91 (, ) J -i I- f--� <br />Permitted Disposal Site 1515- 5. RIVE- ' R2. <br />EH 23 046 (Revised 7/10/96) Page 4 <br />