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ANJtlAQN1NEnvir2'1ffinental Health Department <br /> —COUNTY <br /> 1. (a) Is the current certificate of worker's compensation insurance on file? eE ] NO[(b) Does the contractor possess a"Hazardous Substance Removal Certification"? YEO[ 1 <br /> (c) Has everyone on site,including crane/backhoe operator,been certified to work on YES;K NO[ ] <br /> hazardous waste sites in accordance with CCR Title 8? <br /> 2. Has a"Site Health&Safety Plan"for this job site been submitted? YESX NO[] <br /> 3. Has ap licant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A VV YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[ ] YES[ ] NO Y4. <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain) YES[ ] NO <br /> � GRl�i\ t <br /> 6. If tank residual a fists,identify transoorri.,n azardous waste hauler: <br /> now,,tt <br /> C Na e_ i Hauler Registration# <br /> Address City Zip_ <br /> Phone#( ) <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES[x NO[ ] <br /> b. Identify contractor performing decontamination: <br /> Name S-R�C-+e5 <br /> Address ZSSS17 "- City F20ffsr•6 Zip Q(3ZZZ <br /> Phone No.( 'Sq -tLM—1-130 <br /> C. De cribe rpethod to be used for decont minati n: <br /> /`✓ns-c (vi*I- {ems I- 1'i�.c,o(-c &tea/ <br /> d. Descripe how Isate material will be stored on ite prior to manifesting off$ite: <br /> .�/�uw. frS B/ y4C 4^-16e1C /"tel <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> /Jn <br /> Hauler Name e 4i- � e� t /Hauler Registration# <br /> Address Z�-1 %0L,,,1A e � Do-� City J.A!k zip (O10 <br /> Phone No.( 1 Z q ) o"9"�,o0 rp f� ,+� G <br /> Permitted Disposal Site a �1 GPer6 O 6 6 3 3,5-71- <br /> Z,600 K)C)rVT � � C` - w. ort Cit <br /> 8. a. Describe the meth o that will be utilize t purge nd/or inert the tank ): / ` vs <br /> •" f � ,0 ` �/ <br /> b. Ta i in auler: <br /> Name k/es� [-OC2S� ✓a�S _ <br /> Address City Zip <br /> Phone No.( ) <br /> Hauler Registration#(if hauled as hazardous) C <br /> 4 ISO � <br /> Q�q�� bb�foo <br />.�_ w000tg3jt3 <br />