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1. (a)--Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES ( 1 NO M <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [ j NO M <br /> (c) Does the contractor possess a "Hanrdous Substance Removal Certification"? YES bQ NO ( ) <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title S? YES jq NO ( 1 <br /> 3. Has a "Site Health & Safety Plan" for this job site been submitted? YES X NO ( 1 <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A ( I YES I 1 NO b< If YES, Permit m <br /> d. Has the contractor obtained approval from the local fire department to perform tank cutting? NAK YES( ] NO[ 1 <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES ( ] NO�C] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name (W gams rt /Hauler Registration # 3211v <br /> Address Abu E.1� 1�`0A RikCity Gang t, Zip CI D-LLI <br /> Phone # ( 31 0 ) �Z3 L143O <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES bQ NO f 1 <br /> b. Identify contractor performing decontamination: <br /> Name �Iy'' �l�Am g1 ,(� <br /> Address "I O�D EwSc 1 Npmka City 6)0.4.aU,A Zip C7D24P <br /> Phone No.( 31 <br /> C_ Describe method to be used for decontamination: <br /> RiK. m4�.of1 <br /> d. Describe how rinsate material will be stored ousite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name G)v if aAms Hauler Registration # [b <br /> Address LIMP EaC` A�U.Jhfta City (Ia¢Aano Zip 0I024!( <br /> Phone No. <br /> Permitted Disposal Site Dc N",Jc,-KLRAtM Pot'ti N. Alum.ao L� V, V r1L72,17— <br /> EH 23 <br /> 722ZEH '-3 0a6 (Revised 7/10/96) Page 4 <br />