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0 <br /> 1. (a) Is there a PHS-EIID contractor's questionnaire on file or enclosed? YES [ ] NO (1 <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [vt""/NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification-? YES [l l NO ( ] <br /> 2. Has a 'Site Health &Safety Flan• for this Job site been submitted? YES N NO [ 1 <br /> 3. Has appll t performing removal In the City of Tracy obtained a •cradWg and l�cuvapon permit.? <br /> N/A YES [ ] NO [ 1 If YES, Permit # / <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[gl 'SFS( ] NO[ ] <br /> 5. 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 /> Hauler Registration #Z 5`Y / <br /> Address/>� 3� i(/�•, /{� ;t/ �� City . 7TI�Si Zip lS SE i <br /> Phone # (y�� 1 Se/z <br /> 7. Decontamination Procedures: <br /> e. Will tank(s) and piping be decontaminated prior to removal? YES [til NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name 5'TGc L-fn N c E-P V I C-c :3m -�l C-:, p- <br /> Address pro City sz Jry4% ZipqS-2u/ <br /> Phone No.( ZGC/ 1 Z�t! <br /> C. Describe/method to be Heed for decontaminatlon: <br /> �f n(.ir 1\�•U li for, <br /> d. D be how dnsete material vy]]I be s," onsite prior�o manifesting oRalte: <br /> / [St f1uL l] 1/'-i--LiZla <br /> K L t=iME �, S, V icx S <br /> C. Rlnsate Hauler andpermdtleed Treatment, Stowage,& Disposal racility: <br /> Hauler Namcl2g-C, JC e 1:71AIF_2!�?` V IC;�=j hauler Registration # <br /> Address/3_5'S /V �/L(uL/ •�S Cityrii cwt S[.i� Zip <br /> Phone No. ( Z70 1 n�� <br /> Permitted Disposal Site P�l! �l t }(Vc.C.:/ V/Ce7S% <br /> Page 4 <br />