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1. (a) is there a PHS-EHD contractor's and subcontractor's questionnaire on We or enclosed? YES NO ( ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES VNO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES VNO [ ] <br />(d) Has everyone on site, including cranelbackhoe operator, been certified <br />to work on ham dons waste site in accordance with CCR Title 87 YES (j/ NO ( ] <br />?_ Has a "Site Health & Safety Plan" for this Job site been submitted? YES r( NO ( ] <br />3. Has applicant performing removal In the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA ( ] YES V NO ( J If YES, Permit # <br />4- Has the contractor obtained approval from the local fire department to perform tank cutting? NA( ] YES( ] NO(Ir/ <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES V"'O ( ] <br />,0(C -j -%iL- — -TI-- UA Z -t ;� — (> 0, <br />G. If tank residual exists, Identify transporting hazardous waste bauter. <br />Name [=l/ LF- j Hauler Registration # <br />Address t City N �_, (A, VA, Zip <br />Phone # (- 1 C/'7 �-X — YA'K'- f " <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES (!N0 ( I <br />Identify contractor performing decontamination: <br />Name Ot L.j r— <br />Address 70 GIty4"- 434,1 c -, Zip VC. ,� S_ <br />Phone No&'� a L- / "" 7 0 <br />C. Describe method to be used for decontamination: <br />d_ Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />iN SSS l,� ( DIZUM-s � 6,- S oma, — /U=V�=�Z �1F= <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name /_'. ir-A � r?G Hauler Registration # a 44 a <br />Address i l rA \/ City ►J=GJ A " l/, Zip �f Sib O <br />Phone No. ( Y G Q % <br />Permitted Disposal Site �� ���L �,� • �=,�.1 Q a D 9 SO R 7 41 X <br />EH M 046 Revised 10119198) Page 4 <br />