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Mar -CIA 12 <br />11:49a Elite IV Contactors 12094616342 P.10 <br />/U, J+r) -fl' <br />P b�y U. 0 <br />0 <br />1. (a) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certificatio "? AfSV NO [ ] <br />(c) Has everyone on site, including crane/backhoe operator, been certified to worrl on <br />YES � NO[] <br />hazardous waste sites in accordance with CCR Title 8? <br />2. <br />Has a "Site Health & Safety Plan" for this job site been submitted? YES (g NO[] <br />3. <br />Has.applicant performing removal in the City of Tracy obtained a "Grading and I_a xavation Permit"? <br />N/A W YES (I NO [] If YES, Permit # <br />4. <br />Has the contractor obtained approval from the local fire department to perform to il, : utting? NAj kYES[ ] NO[ ] <br />5. <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If ye::, I case explain) YES [ ] NO FLX <br />6. <br />If tank residual exists, identify transporting hazardous waste hauler: <br />Name �,(A[iti f�t�a1 E'Cl'(ifk�i`)Iut ��t'.rt�i '�� Hau a Registration# (ADC`Kij% <br />Address 4. i!J ,'a PS -1. City®1�Zip ((f <br />Phone #( F t " 0I ai J <br />7. <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ NO [ ] <br />b. Identify contractor performing decontamination: <br />Name C111`ld` i r jwi rm f'y�.!-P►i'i`Lf ( sea"( -c i <br />Address _ } ] J �, `i1iV � t City I .t>'•[; , i Zip %V (1 <br />Phone No.(C1 I Lp) 3 t ] - 9 5;- <br />c. Des 'be method to be used for decontamination: y �� (' �(�/�3s�� <br />I `' r c� (xi (1 _ _ b <br />E LrQ X _ <br />d. Wcribehowrinsate ate 'al will be stored onsite prior to manifesting.c. i:e:i„ <br />e. Rlnsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name k(],r o cs. l� {�il; + Yi' E }_j'Y?i'i'7�GE f JC'iLt �I --ler ogistration # 0 5 1 <br />Address_1 J i `{-C'x �r1 -- City it " x r Zip C b �% t <br />Phone No. <br />Permitted Disposal Site -2AMon L •.(iii42:naymat <br />8. a. 1pscribe the method that will be utilized.to purge nd/ rine, a tank(s): ++ 1 `/� <br />^� i' �t✓ <br />b. Tank/Piping Hauler: <br />Phone <br />Hauler Registration # (if <br />City _ _® Zip <br />as hazardous) _ <br />EH 23 046 (Revised 07/22/10) 4 <br />