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u <br />• <br />1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, Including cranelbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 87 <br />2. <br />3. <br />4. <br />5. <br />6. <br />7 <br />Has a "Site Health & Safety Pian" for this job site been submitted? <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/AX YES NO[] If YES, Permit # <br />YES M NO [ ] <br />YESW NO[] <br />YES H NO[] <br />YES H NO[] <br />YES[H NO[] <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NON <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO W <br />If tank residual exists, identify transporting hazardous waste hauler <br />Name � I ntw l ('W V4 -n- Cy (31(- Hauler Registration # <br />Address i, O. 1� L )( 3 q 0 City tel- « Z Zip <br />Phone # ( ?�SO ) '� 3A - Zi b 4 5 <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />b. <br />C. <br />d. <br />e. <br />Identify contractor performing decontamination: <br />Name SEMCO <br />Address 1217 South 7th Street <br />Phone No.( 209 ) 524-9653 <br />City Modesto <br />3 -7 ply <br />ci S `� ! 'i <br />YES[d NO[] <br />Zip 95351 <br />Describe method to be used for decontamination: <br />The tanks &_piping will be triple rinsed at 180° using a low volume, <br />high pressure washer. The first rinse will include the use of a bio- <br />degradable detergent. The two final rinses will be clean water. <br />Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />The rinsate material will be stored on site in DOT 55 gallon drums <br />with apprnnriatP 1ahP1G_ <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name e4 /l? C-R i Clh� v 'L,1 i Hauler Registration # r <br />Address -P, () , 'E�b � I/ D City <br />Phone No. ( li�D ) �7 3 1�, — y b q S <br />-bc.. r+r <br />Permitted Disposal Site 104 LOU S' M I ni S 6Y2 V/ C i� 01 L [ /Yr C . <br />EH 23 046 (Revised 10/19/98) Page 4 <br />Zip 453 5 <br />