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<br /> <br /> <br />4 of 10 <br /> <br />Environmental Health Department <br />1. (a) Is the current certificate of worker's compensation insurance on file? YES [ ] NO [ ] <br /> (b) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ ] NO [ ] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work on YES [ ] NO [ ] <br /> hazardous waste sites in accordance with CCR Title 8? <br /> <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [ ] NO [ ] <br /> <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A [ ] YES [ ] NO [ ] If YES, Permit # _____________________________________ <br /> <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES [ ] NO [ ] <br /> <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [ ] <br />____________________________________________________________________________________________ <br />____________________________________________________________________________________________ <br /> <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br /> <br />Name________________________________________________ Hauler Registration #_____________ <br /> <br />Address________________________________________ City_________________ Zip______________ <br /> <br />Phone # (__________)__________________________________________________________________ <br /> <br />7. Decontamination Procedures: <br /> <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO [ ] <br /> <br />b. Identify contractor performing decontamination: <br /> <br />Name _______________________________________________________________________________ <br /> <br />Address _______________________________________ City _________________ Zip ______________ <br /> <br />Phone No.(__________)_________________________________________________________________ <br /> <br />c. Describe method to be used for decontamination: <br />_____________________________________________________________________________________ <br />_____________________________________________________________________________________ <br /> <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />_____________________________________________________________________________________ <br />_____________________________________________________________________________________ <br /> <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> <br />Hauler Name_________________________________________ Hauler Registration #______________ <br /> <br />Address________________________________________ City _________________ Zip______________ <br /> <br />Phone No. (__________)________________________________________________________________ <br /> <br />Permitted Disposal Site__________________________________________________________________ <br /> <br />8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br />_______________________________________________________________________________________ <br />_______________________________________________________________________________________ <br /> <br />b. Tank/Piping Hauler: <br /> <br />Name__________________________________________________________________________________ <br /> <br />Address________________________________________ City________________ Zip _________________ <br /> <br />Phone No.(__________)____________________________________________________________________ <br /> <br />Hauler Registration # (if hauled as hazardous)__________________________________________________ <br />