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0 <br />Tt{ <br />I. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclbSed? YES K' NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on riled =r° �, YES [-J' NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"''{ {' YES [-r NO ( ] <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES K'NO [ ] <br />3. <br />4. <br />Has a "Site Health & Safety Plan" for this job site been submitted? <br />YES [-I---'NO [ ] <br />Has app <br />,kVant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A[ -IF YES [ NO [ ] If YES, Permit # <br />Ir r <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[r]'NO[ j <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [rKNO [ <br />TIA4-=LTL=.( &Ag P'E:ffN �/�tn-rtQEa rrll <br />,q-nt nr llLA 2 5.�l4t � <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name NOPC444- Ott-, t AJ(f , Hauler Registration # <br />Address P O. rsOX 4,KSS City T)e^t A f Zip 47S314 <br />Phone #( Z09 ) 900-33Z-27/0 <br />7. DecontaminationProcedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES WNO [ ] <br />b. Identify contractor performing decontamination: <br />Name /VO2 CA(.- O / G.. /A(<*, <br />Address �O /�� �� f5 City ���� zip <br />Phone No.( 709 ) 6G-7 — 8Y 6F SOO 3-3Z-37/0 <br />C. Describe method to be used for decontamination: <br />��y lCC Tit/fL-E7 ZfA 5/A!4�2 <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />VACLIusf�e <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name M04 C14L ®(L, 1^1C Hauler Registration # Zy' <br />Address O isbx city i/y R ( C zip <br />Phone No. ( �-) 6C, 7 5>4619 800 — 3 Z - 0'710 <br />Permitted Disposal Site I�etc�rl NC.- Zs7b A-imotel D �Z- <br />5/20 SlLv� SP�^/6S , NY <br />EH 23 046 (Revised 9/11/96) Page 4 YLI <br />AIYD ?8Z. 356 q93 <br />