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n <br />u <br />1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES ["1NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES [vj/ NO [ ] <br />(c) Does the contractor possess a "Hazard n Substance Removal Certification"? YES NO [ J <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 [vJ/ NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES ] NQ [ ] <br />�'(O 't" eA <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A [v)� YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[(YES[ J NO[ J <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO Y] <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name 92LNd 017 tN V i N j: T L Hauler Registration # ®, 1,4b <br />Address *1'2 Ufli F-IVPM City W' TO Zip Ofi 621 <br />Phone # <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />Address -city zip <br />Phone o <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored o site prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name I Hauler Registration # <br />Address City Zip <br />Phone No.( ) <br />Permitted Disposal Site <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />