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11 <br />E <br />t. (a) Is the current certificate of worker's compensation insurance on file? YES [ ] NO[] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES(] NO(] <br />(c) Has everyone on site, including crane/backhoe operator, been certified to work on YES NO [ ] <br />hazardous waste sites in accordance with CCR Title 8? [ l <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES(] NO[] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A f ] YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NO[ ] <br />6. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (if yes, please explain) YES (] N0 <br />6. if tank residual exists, identify transporting hazardous waste hauler. kll#- <br />Name Hauler Registration # <br />Address City Zip <br />Phone # ( ) <br />7. Decontamination Procedures: <br />a. Will) <br />and piping be decontaminated prior to removal? YESV NO [ ] <br />b. Identify contractor performing decontamination: <br />Namf'liY�%PX1'1 <br />Address I i ®U City ®^ Zip <br />Phone No. _) K 3D 2— <br />C. Desc tb me od to used for deconta nation: <br />d. <br />e. <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: . <br />Hauler Name Hauler Registration # <br />Address City Zip <br />Phone No, ( ) <br />Permitted Disposal Site <br />8. a. Ile e h method that will be utilized to purge and/or inert the tank(s): <br />Ij <br />b. Tank/Piping Hauler, <br />Name <br />Address City Zip <br />} Phone No.( ) <br />Hauler Registration # (if hauled as hazardous) <br />EH 23 046 (Revised 07/22/10) 4 <br />