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r1. (a) Is there a PHS- contractor's questionnaire on file or enclosed? YES NO I ] <br /> (b) Is the current certificate of worker's compensation insurance on Gle? YES NO [ I <br /> (c) Does the contractor possess a 'EUaardons Substance Removal Certification'? YES NO [ ] <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading d Ekczvation Permit'? <br /> N/A [ ] YES [ ] NO [ ] If YES, Permit # f}f <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAArYES[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tanks) and/or iping? (If yes, please explain)/YES NO N <br /> /�C��-GG��J <br /> 6. If tank residual exists, identify transporting <br /> ttJransporting hazardous waste hauler. <br /> Name /E7/LOGCHauler Registration # ��Sg <br /> Address A,)A ,{� /93 City 0,00E57e Zip 9S35L <br /> Phonem Z( Og ) S�6 SSDO <br /> 7. Decoutaminatioa Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal' YESefr NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name S�/11G0 <br /> Address /Z/� TH �fy �77L�ET City Zip <br /> Phone No.( 209 ) SLS 9653 <br /> C. Describe method to be used for decontamination: <br /> THE Tyt5 AV D 102AAA'6 411146 156 MOee 4 ASc'D .47- /grO usitib f} [.ow <br /> (/D 16A P&AIEt, 7,Ye <br /> *5S T ,06 E' 0A <br /> A O&7W6Sdr 7-At r&JO CqSE <br /> l?ic?- dE 64E.ty tvth E2 <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> 7l/G X11V4 f7E ,BE S7214.6�b <br /> OFtta,S (//T/1 9P/fd/pAfirE G4hEL5 <br /> e. Rinsate Hauler and permitted Treatment, Storage &Disposal Facility: <br /> Hauler Name f{LL/Ep pE7/2DGEG!/y/ Hauler Registration * //SB <br /> Address P,O. Aor /93 City ,1100ESTd Zip gs35-2 <br /> Phone No. <br /> Permitted Disposal Site �EF/N�R�J fy�eES� r�!?76PSON, C�� <br /> Page 4 <br />