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SANJ O A Q U I N Environmental Health Department <br /> 1 . (a) Is the current certificate of worker's compensation insurance on file? YES NJ NO [ ] <br /> (b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES N(] NO [ ] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work on YES N) NO [ ] <br /> hazardous waste sites in accordance with CCR Title 8? <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES M NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A A YES [ ] NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES [X NO [ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain ) YES [ ] NO [x] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name ACT ENVIRO Hauler Registration # CARo00070�,40 <br /> Address 967 MAYBURY RD . City SAP! JOSE Zip 551 ,t3 <br /> Phone # ( 866 ) 333-9222 <br /> 7. Decontamination Procedures : <br /> a . Will tank(s ) and piping be decontaminated prior to removal? YES [M NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name ]NNOVATIVE CONSTRUCTION SOLUTIONS ( ICS ) <br /> Address 2525 STANWELL DRIVE , SUITE 200 Cit, CONCORD Zip 94520 <br /> Phone No . ( a2F ) 97A nCnC <br /> c. Describe method to be used for decontamination: <br /> TRIPLE RINSE PIPING AND TANK INTERIORS WITH ORGANIC SURFACTANTS (SIMPLE GREEN) <br /> COLLECT RINSEATE VIA VACUUM TRUCK <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> RINSEATE WILL BE STORED IN 250 GALLON TOTES , PENDING ANALYTICAL AND PROFILE APPROVAL <br /> TnTFR WII I RF PROPFRt Y MARKFn ANTI I ARFI Fn ANn PI Ar. Fn INTn CFrnNnARY (' () NTAINMFNT DN SITE <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name ACT ENVIRO Hauler Registration # CAR000070540 <br /> Address 967 MAYBURY ROAD City SAN JOSE Zip 95133 eeew <br /> Phone No. ( 866 ) 333-9222 <br /> Permitted Disposal Site CROSBY AND OVERTON 1630 W. 17TH STREET, LONG BEACH CA. CAD028409019 <br /> tt�op (562 )432-544pp5rq tank(s): <br /> 8. a. Describe IRINSE IINTCRIOR , UbTINSPECTII N WINDOWS , INERT TANKS WITH DRY ICE <br /> ATA RATE OF 3 LBS. PER 100 GALLON OF TANK PIPING WILL BE DEGUNIAMINATED ON SIIE AND HAULED <br /> b. Tank/Piping Hauler: AS NON-HAZARDOUS DEBRIS TO A LOCAL CLASS III LANDFILL <br /> Name NAMAN TRUCKING INC . <br /> Address 28465 CHRISMAN ROAD City TRACY Zip 95304 <br /> Phone No.( 209 ) 650-6649 <br /> Hauler Registration # (if hauled as hazardous) TANKS AND PIPING WILL BE HAULED AS NON- HAZARDOUS <br /> TO HAY ROAD LANDFILL <br />