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E1 <br />1. (a) Is the current certificate of worker's compensation insurance on file? YES [J NO [ ] <br />(b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [J NO[] <br />(c) Has everyone on site, including crane/backhoe operator, been certified to work on <br />hazardous waste sites in accordance with CCR Title 8? YES [ J NO[] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [A NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A [I YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAU YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [ ] <br />xx <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name Adams Services Hauler Registration # 3216 <br />Address 406 East Alondra Blvd City Gardena Zip 90248 <br />Phone # ( 310 ) 523-4430 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />a <br />Identify contractor performing decontamination: <br />Name Adams Services <br />Address 406 East Alondra Blvd <br />City Gardena <br />S NO[] <br />q <br />`A <br />Phone No.( 310 ) 523-4430 ffi111 <br />C. Describe method to be used for decontamination: <br />Tank and lines will be blown back. Tanks will be triple rinsed. Dry ice will be used to inhert the tank. Once LEL mr�r rid 1 <br />approval from inspector tank will be removed. <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />Rinsate material will be stored in DOT drums and removed by Adams Serives. <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Adams Services Hauler Registration # <br />Address 406 EastAondra Blvd City Gardena <br />Phone No. ( 310 ) 523-4430 <br />Permitted Disposal Site DeMenno/Kerdon <br />Zip 90248 <br />a. Describe the method that will be utilized to purge and/or inert the tank(s): <br />Lines will be blown back. Dry ice will be used to inhert the tank. LEL Meter will be used to detect any LEL's prior to remvoal. <br />20 pounds per 1000 gallons will be used. For a 12,000 gallon tank, 240# of dry ice will be used. <br />b. Tank/Piping Hauler: <br />Name Adams Services <br />Address 406 East Alondra Blvd City Gardena <br />Phone No.( 310 ) 523-4430 <br />Hauler Registration # (if hauled as hazardous) 3216 <br />EH 23 046 (Revised 7/26/2016) 4 <br />Zip 90248 <br />