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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO [ <br />(b) Is the current certificate of worker's compensation insurance on file? YES NO ( ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ ] <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 [ ] <br />2. Has a "Site Health: & Safety Plan" for this job site been submitted? YES (] NO <br />3. Hasapplicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A YES ( ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? N YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name ] 116- . Hauler Registration # 00 1 <br />Address l t--VtP> City -RIC t4 zip 94aol <br />Phone # ( 15 10 ) VS5 ®- 1 <br />7. Decontamination Procedures: <br />a. Will U piping be decontaminated prior to removal? YES NO ( ] <br />b. Identify contractor performing decontamination: <br />Phone No.( 1 ) —1 <br />C. Describe method to be used for decontamination: <br />�(f 1 rJ C9 't"y ?.I ti! caut• � r.1"i0 '`i'nt t <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />NAL. <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Itr [NG, Hauler Registration # C?( <br />Address AVZr, VV City le,14 zip [ <br />Phone No. ( 1t) ) - ] 3 <br />Permitted Disposal Site l i4G ! 1 p <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />