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1. (a) Is there a PIIS-EIID contractor's questionnaire on file or enclosed? YES [ ] NO <br /> (b) Is the current certificate of worker's compensation Insurance on file? YFS [v],N0 [ ] <br /> (c) Does the contractor possess a Muardous Substance Removal Certification'? YES i NO I <br /> 2. Iies a 'Site Health &Safety Plae for this job site been submitted? YES M-'NO [ 1 <br /> 3. flag up if t performing removal In the City of Tracy obtained a 'Grading and Umcavalion Permit"? <br /> N/A YES [ ] NO I ] It YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA['t3' [ ] NO[ l <br /> 5., is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO <br /> r <br /> b. if tank residual exists, Identify transporting hazardous waste hauler: <br /> Name .C1.� J� (— &L_ �,� V t( - Hauler Registration <br /> Address _� r u z. S � Cityd-rrcc -�,i' A� zip %.- -SI-3 <br /> . <br /> 7. Decontamination Procedures: <br /> a. W111 tank(s) and piping be decontaminated prior to removal? Y-S [tirNO [ ] <br /> b. Identiry contractor performing decontamination: <br /> Name 5-T-Cf( kTF� i�' lCCf'�Tie•:� Cn. y, t� <br /> Address ' ' `S � _._ City Zip '7 <br /> Phone No.( oe- I <br /> C. Describe Vxelhod to be used for decontamination: <br /> d. De ribe how rinsate material w-U1 be sq"d onsite prior po maniresting offsite: <br /> `rr'(E.s.t <br /> e. Rinsate hauler and permitted Treatment, Storage & Disposal Facility: <br /> IluuferNameJ`Sc_ IY/Aft'. +' _��L` .S Hauler Registration # •, � <br /> Address/_3. /V. f �� ti Clty �� 'SO IJ zip <br /> Phone No. •( ,_� <br /> Permitted Disposal Site � Lr�fN`�_-b'b'l <br /> Page 4 <br />