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Ll <br />C <br />1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? YES [� NO [ <br />YES <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? [� NO [ <br />YES <br />(d) Has everyone on site, including crane/backhoe operator, been certified (� N®[ [ <br />to work on hazardous waste site in accordance with CCR Title 8? <br />YES [i,}� NO [ <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />YES [ I No l l <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A [ I YES [ I NO [ I If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAWYES[ I NO/j <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ I NO <br />6. If tank residual exists, tidentify transporting hazardous waste hauler: <br />Name_ r—C.- - n nL Hauler R -ftn-1 —Z3 V ? 3 <br />egistration # _ <br />Address `ZSS� �� �(� B� �� City 1 (ALO d Zip t(�f7 i <br />Phone # <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />YES &ANO[I <br />b. Identify contractor performing decontamination: <br />Name riS I CM° 1 Y\ L <br />Address P (�, j�( 1 t (� City v —Zip 6 <br />Phone No.C�� <br />C. Describe method to be used for decontamination: <br />- ,� -r—, ,. ► n �" k V °i� IJ-� � ®� S C C)Y� r�Gl" IP r pP <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />OP <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name � % rf� , I,,, . <br />Hauler Registration # CAD. '29>2D36i73 <br />Address '� ! -R- —_ City ✓,1 { i ` d <br />Phone No.�d b <br />Permitted Disposal Site�(��.—�[%�.� <br />EH 23 046 5/20 <br />(Revised 9/11/96) Page 4 <br />