Laserfiche WebLink
1 <br />L•l <br />(a) Is the current certificate of worker's compensation insurance on file? YES [AK NO [ J <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [1]/ NO [ J <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 K NO[] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [+j'NO [ j <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A D< YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAtA 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: <br />Name <br />Name I �i� 1I11 P1� �J%[ lJ�l Hauler Registration #314 <br />Address �C 3-1C' City Zip - 56b <br />Phone # ( L' ) 3�. 4t D 45 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? ✓V A . YES[] NO[] <br />b. Identify contractor performing decontamination: <br />Name C �i` �� Ci (:,YICI('. S <br />C. <br />G <br />e. <br />a. <br />Address , o G // am //- r City �)�`� )'� Zip C15� <br />Phone No.( `� — IIJ33i <br />Describe method to ha i icari fnr riarnntaminatinn- <br />� I ! w d -h o lean i�1c �C C// <br />j � - <br />Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />Rinsate Hauler and permitted dTrreatment�, Storage & Disposal Facility: <br />Hauler Name ill/ i 1 � i �ku Hauler Registration # �Y y <br />Address C� co Ly Citypdb � Zip C <br />Phone No. <br />Permitted <br />Describe the method that will be utilized to purge and/or inert the tank(s): <br />b. Tank/Piping Hauler: IV0 1 <br />Name <br />Address <br />Phone No.( ) <br />Hauler Registration # (if hauled as hazardous)_ <br />EH 23 046 (Revised 07/22/10) 4 <br />Zip <br />M <br />