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(let <br /> 1. (a) Is the current certificate of worker's compensation insurance on file? O YES M NO[j <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YE NO[] <br /> (c) Has everyone on site,including crane/backhoe operator,been certified to work on <br /> hazardous waste sites in accordance with CCR Title 8? YES NO(j <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 Permlt"? <br /> N/A,K YES(] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NAX 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: AIA <br /> Name Hauler Registration# <br /> Address City Zip <br /> Phone# <br /> i <br /> k <br /> 7. Decontamination Procedures: N <br /> t <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES[] NOVA <br /> b. Identify contractor performing decontamination: <br /> 4 <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> i <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name Hauler Registration# <br /> Address City Zip <br /> Phone No.( ) <br /> i <br /> Permitted Disposal Site <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): j <br /> v FIL <br /> b. Tank/Piping Hauler. <br /> Name WifIROrt VI cel 7NC. <br /> Address IG(ou V%- 57126k- City GAKEkSM4.0 Zip 3505 <br /> i <br /> Phone No.( 9 L <br /> Hauler Registration#(if hauled as hazardous) NA <br /> i <br /> EH 23 046 (Revised 8/1/11) 4 <br />