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r 1. <br />2. <br />3. <br />4. <br />5. <br />0 0 <br />(a) Is there a PHS -EEM contractor's 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 Certificatiou'? <br />Has a 'Site Health & Safety Plan' for this job site been submitted? <br />YES NO [ ] <br />YES [�j NO [I <br />YES NO [ ] <br />YES NO [ ] <br />Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A [ ] YES ( ] NO [ ] If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAArYES[ ] NO[ ] <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [ ] <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name �LG(�f) �E72dLCu/�? Hader Registration # / 5' <br />Address �O. "fe't /93 Clty /7%OOES%0 Zip 95-35Z <br />Phone"( Z( 0l ) -476 ¢i'SOO <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? Mer NO ( ] <br />b. Identify contractor performing decontamination: <br />Name 5i/ C0 <br />Address /Z/Z �Tdf eET City Al%GeESry Zip 9. 5367 <br />Phone No.( 5-09 ) 5-z4/ 9653 <br />C. Describe method to be used for decontamination: <br />7'NE TiUtS AIVP 4/,0/1PA /W16 Y6 ZMPLE P1ir SGL er Me , a!;1,V44 A- z44 <br />01C <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />7W.A-r- XIV 47E "7W0h1f. 411,Yi 66- $fb/2653 OkSrrE /N &7 ��C S$ AALGOr <br />ORuA�S 4//7& 44tS& .s <br />e. Rinsnte Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Namee� l�LC./EO 1471ZjLEaw, Hauler Registration# //68 <br />Address P,4. 'Rer /93 City Zip 535 2 <br />Phone No.( Og ) ✓rn e�.SOO Q <br />Permitted Disposal Site �EF/N�R�j .S6yCdIGES r�t?T54i0/V, L�.� <br />Page 4 <br />