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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES [ ] NO <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [ ] NO <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification`.' YES 7 ' NO <br /> 2. Has a 'Site Health & Safety Plan'for this job site been submitted? YES /( ] NO p(j <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit`! ` <br /> N/A [ 1 YES [ 1 NO g4 If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAYES[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain)`YES [ ] NO N <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. C-A Ip yZ JP-t{2 a <br /> Name t E„ric�CSJo <br /> oJ� _ L �c.. Hauler Registration #cADgq(0639Z <br /> Address �� po.r r- -1:�1\JA City �"tne.l Zip q j'4 l <br /> Phone # ( SI a <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address WLI-- CoIoMa City /Gni1J (ruj!/✓a Zip 6 C) <br /> Phone No.( G(,i <br /> C. Describe method to be used for decontamination: <br /> Le <br /> d. Describe 1how rinsate material will be stored onsite prior to manifesting offsite: 7' <br /> ]SMAS o� 2i) ,C,i/ �t>,( -� " &An 0 r C,4 i J&I tZA r !� Govt <br /> jrg�T nr4-o � is 'Pecl'.vsor L„r_ -�FIr c�.R�t� <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: c4)o_Y2 7Y78 <br /> Hauler Name �f,z.6,Sj y� EAC /Hauler Registration #.f—j4 7, <br /> SIO 4 39 <br /> Address 2SS Prnrr R iJd City gad ,,\A \j Zip "} o <br /> Phone No. sip <br /> ` ' <br /> Permitted Disposal Site QO.Tt e 1 So ri .i VI L On f/�A4ers0r1 CA. C1134 1536 <br /> Page 4 <br />