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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES [ ] NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on Me? YES [ ] NO [" - <br />(c) Does the contractor possess a "Hazardous Substance Removal CertMeatlon"? YES NO [ ] <br />(d) Has everyone on site, including cranelbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES WINO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES W NO ( ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA [ ] YES [ ] NOW If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NOe <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO K," <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />NameC / Hauler Registration # 019 <br />Address 2 ST P4 RR 81-Vd,RICA/A701VIO Zip 9 8 0/ <br />Phone #( 0 ) Z3_6_-/323 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES eNO [ ] <br />b. Identify contractor performing decontamination: <br />Name ECI <br />Address BLYO, I Zip 9-f i <br />Phone No.( 510 ) 2_3S-1392 <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />1AJ 54 T£ W1Z4 A10 46 ST01?E0 SIS <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name CC / Hauler Registration # 0/ 9 <br />Address 5 FAXR 846.). City R l oyeyon Zip 01 <br />Phone No. 0 <br />Permitted Disposal Site Roiwc ciyenlewz, ® Y P. , 1-1 Z.o A4 r0 <br />EH 23 046 (Revised 08113199) Page 4 <br />