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1. ✓(a) Is there a EHD contractor's and subcontractor's ss questionnaire on file or enclosed? <br />✓(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including crane/backhoe operator, been certified to work on <br />(e) hazardous waste site in accordance with CCR Title 8? ee <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? 4 <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavatic <br />N/A YES [I NO [I If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutti <br />NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please <br />NO)( <br />6. If tank residual exists, identify transporting hazardous waste hauler: fq+ <br />Hauler Registration <br />City--Dip— <br />Phone <br />Phone # <br />7, Decontamination Procedures: NW clasQ / �a cQ <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ <br />b. Identify contractor performing decontamination: <br />Name <br />Address <br />City <br />Zip <br />Phone No., <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name_ <br />Address <br />Phone No. <br />\ Permitted Disposal <br />EH 23 046 (Revised 3/15/02) <br />Page 4 <br />City <br />Hauler Registration <br />(] NO[] <br />[l NO[] <br />Ll NO[] <br />[] NO[] <br />[] NO[] <br />NA)J YES[ ] <br />YES (I <br />NO [I <br />