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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on rile? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 3? <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />3. <br />4. <br />5. <br />6. <br />7 <br />YES NO [ I <br />YES (X NO[ <br />YES ( NO( J <br />YES [X NO ( I <br />YES [X NO ( I <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A j YES ( j NO (j If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA[X YES( I NO[ <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If ,yes, please explain) YES [ I NO k] <br />If tank residual exists, identify transporting hazardous waste hauler: <br />NameErickson, Inc. Hauler Registration # <br />Address 255 ParrBlvd. CitvRichmond Zip <br />Phone Y( 510 )235— 1393 <br />Decontamination ares: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [)t NO [ j <br />b. Identify contractor performing decontamination: <br />Name Kvaerner Aronson, Inc. <br />Address 11297 Coloma Road CiMancho Cordova Zip 95670 <br />Phone No.( 916 ) 631-1646 <br />C. Describe method to be used for decontamination: Triple Rinse <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />After rinsing the UST, the rinsate material will be removed <br />and manifested for disposal according to current regulations. <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Erickson, Inc. Hauler Registmtiou #1533 <br />Address 255 Par'Blvd. City Richmond Zip <br />Phone No. ( 510 ) 235- 1393 <br />Permitted Disposal Site ECI — 255 ParrK31yri- Vb C44- <br />5120 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />