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S 1 . (a) Is the current certificate of worker's compensation insurance on file? YES (xj NO [ ] (b) Does the contractor possess a " Hazardous Substance Removal Certification" ? YES [xi NO [ ] (c) Has everyone on site , including crane/backhoe operator, been certified to v.tork on hazardous waste sites in accordance with CCR "i itle 8? YES NO [ J 2 . Has a "Site Health & Safety Plan " for this job site been submitted? YES [xJ NO [ ] 3. Has applicant performing removal in the City of Tracy obtained a " Grading and Excavation Permit"? N/A Pq YES [ J NO [ J If YES , Permit # �i . Has the contractor obtained appy oval from the local fire department to perform tank cutting ? NA[ ) YES( j NO [ ) 5 . Is there knowledge or evidence of le kage from the tank(s) and/or piping? ( If yes, please explain) YES O NO (aJ 6 . If tank residual exists, identify transporting hazardous waste hauler: Name American Valley ' laste Oil Hauler Registration # 3744 Address P . O . Box 340 City Delhi , CA Zip 95315 Phone # ( 800 7324645 7 , Decontamination Procedures : a . Will tank(s) and piping be decontaminated prior to removal? YES [x] NO [ J b. Identify contractor performing decontamination: Name Advanced GeoEnvironmental, Inc. Address 837 Shaw Road City Stockton Zip 95215 Phone No. 209 ) 467- 1006 C* Describe method to be used for decontamination : Any nominal liquid in tank will be removed via vacuum truck; then the tank will be triple-rinsed using a green cleaning agent such as "Simple Green"/ d. Describe how rinsate material will be stored onsite prior to manifesting offsite : Rinse material will be immediately transferred to a pump truck for disposal . However, if any liquid as to remain on-site , it will e placed into DOT,wrated , a eIe , -ga . on drums, e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Hauler Name American Valley Waste Oil Hauler Registration # 3744 Address P . O . Box 340 City Delhi , CA Zip 95315 Phone No . ( 800 7324645 Permitted Disposal Site Dk Dixon , 7300 Chevron Way, Dixon , CA 95620 ( EPA CAT080012602) 8. a . Describe the method that will be utilized to purge and/or inert the tank( s ) : 15 lbs of dry ice per 500-gallon of tank volume will be used to "inert" the UST. b . Tank/Piping Hauler: Name West Coast EquipmentREr . F I V E E Address P . O. Box 2368 City Turlock, CA Zip 95381 SE" 8 2016 Phone No . ( 800 441 -8544 Hauler Registration # (if hauled as hazardous) N/a - Tank will be transported as Non-Haz. l= NIV R ( 1NIk4_Gli TAL HEALTF DEPARTMENT EH 23 046 (Revised 7/26/2016) }