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SA N 1 a A Q U I N Envirm49tnantal Health Depart- ens; <br /> C- sC) U 1`•I T 1, Costco Fuel Facility #1091 / Our Job No. 14573.11 <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"? YESbt[ NO [ ] <br /> (c) Has everyone on site, including crane/backhoe operator, been certified to work on YE 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? YESA NO [] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A YES [j NO [j If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform lank cutting? NAK YES [ j NO [ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO,0 <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name�IDA)It5 -5!�- VTZ,C ,5 'T- j C Hauler Registration # -3 L <br /> Address city zip K 2 3 <br /> EPAID#: C Ar?, Coo 1 ,99t-1- i <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YESPr NO ( ] <br /> b. Identify contractor performing decontamination: <br /> Name 4U��.JUL j��7ZP�`r f ill>r]1�r� sC7z 1f�C <br /> Address City Zip <br /> c. Describe method to be used for decontamin tion: <br /> !V-,rI72 0l;C-IJ fZ Si` tr� lv.g rz -� <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> V'ACyujK •TjzVCK <br /> e. Rinsate Hauler permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name /-1T71a!`S 3C RV�5 C _ Hauler Registration <br /> Address y 4� i>3/C'�4�/3)3&✓i> • City Gr'S12j7C�� zip-- , l� <br /> EPAID#: _<.:AR (202 leg�-i <br /> f. Permitted Treatment, Storage&Disposal Facility: <br /> Name WQ[ -D 0'L Hauler Registration# I� /A <br /> Address 2 000' N .. AI-All 1&T A 5% City t`.t7 M P%v Zip <br /> EPAID#: C_;A7' 0cr''ac'7 D13 35z <br /> 8. a. Describe the method that will be utilized to purge and/or inert the tank(s): <br /> lg/zY xCC A CL OA",�` 6; <br /> b. Tank/Piping Hauler: <br /> Name dA1Pj(/l e7Z- j 11iG({; J([ Hauler Registration# <br /> Address 19555 CA `� `i / City '`n 2-21''Il c' Zip C� S2 <br /> EPA ID# (if hauling as hazardous): Nl R <br /> 2 <br />