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1. (a) Is the current certificate of worker's compensation insurance on file? YES <br /> (b) Does the contractor possess a"Hazardous Substance Removal Certification"? YES(.•jj'' Oil <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 NO(J <br /> 2. Has a"Site Health 8 Safety Plan"for this job site been submitted? —b-itu-8E YES[] NO() <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? WJA <br /> N/A[] YES(] NO[I If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform lank cutting?NA[4`YES[I NO[I <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO t�f <br /> 8. If tank residual exists,identity transporting hazardous waste hauler: <br /> Name,'baMA-1 Hauler Registration# e QK poo I $C(N3 <br /> Address '1r)(o � .A{gt`I1�13-P- glv� City Ct,"at`lA Zip Q01y0 <br /> Phone#( 310 ) 5a3 -44x0 <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 ADAMS /A/C• <br /> Address 406 C •ALol I0AAA RLJU . City C�ARISENA Zip g0.1'�ll <br /> Phone No.( 3(0 1513 —`4`/30 <br /> C, Describe method to be used for decontamination: <br /> T2/Ac e/&f'—_E /Pa¢ Ti rte Z2 Rif✓��`MeA/l`y <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> RtA/5/F7�wrtC- BE co/+6eD ON VXCLOMMOck Flom hW((& JNAUUF6 OF=F r,/L <br /> S!!C 6A-ME 13A <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name A//A/)jS SE/zt/tCE<, /Ak - Hauler Registration# 3'"d CbTSc.) <br /> Address V06 �F- Acol/lneA A(-VD . city G;PA126g&IA- Zip qo a*j <br /> Phone No.( 3!0 ) S23 — 7,/3 O <br /> Permitted Disposal Site �SE McA/A/D (V:,/tjAwt 2 o0 N. ACA A16,0A � 7-Lt CoM -90W CA 40 z. L <br /> A//j 310) &37 -7(DO 4PA — cA o$0 ora 3Si <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> /Algry r /�/trWD 't tc. !,; PER- /ay c,t4U.00f5. <br /> i <br /> b. Tank/Piping Hauler: <br /> Name AbAMS SE/eVtC6S /✓� . <br /> Address y06 F A-GDA/[)/tA`lbC�> City C7R9,0,j-VA- Zip <br /> Phone No.( 3('0 ) S23 <br /> Hauler Registration#(if hauled as hazardous) /(IA tMfkS A,51dir NA"n As A(Od 9Abk0,tb0S <br /> E1123046 (Revised8/I/II) 4 <br />