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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />YES <br />NO [ j <br />(b) Is the current certificate of worker's compensation insurance on file? <br />YES <br />NO [ j <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />YES [►')' <br />NO [ J <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 />YES [rj' <br />NO [ j <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />YES [✓� <br />NO [ j <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A N YES [ I NO [ j If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAV(YES[ <br />j NO[ j <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? <br />(If yes, please explain) YES [ ] NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Pik -JF - <br />Name ge,Iwt;o4 , INY, • Hauler Registration # <br />Address I�P5 el'•yp City 12ic44mo4o Zip14'&(5 <br />Phone # ([ ® ) <br />It 1770z.-- <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ j NO <br />b. Identify contractor performing decontamination: <br />Name <br />Address City Zip <br />Phone No.( ) -- <br />c. Describe method to be used for decontamination: A/ <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: q <br />Hauler Name G kZO A1' Det 5"' ' Hauler Registration # 00 <br />Address 45- 1114J? -0_ g�p City ip �____. J <br />Phone No. ( �d ) <br />?sib- X393 ®�- 910-'14-Gv2 <br />Permitted Disposal Site PD071C' U/A9?0A1, iI %79-(--- <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />