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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? Sp q, YES K NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES x] NO [ ] q4[ e <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification'? YES 0Q NO [ ] <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES bQ NO [ ] <br /> 3. Hasapplicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br /> N/A K YES ( I NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAN YES[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO rY <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. � ��l-(r bl <br /> Name rrl Srn T.)r . Hauler Registration # 001q <br /> y <br /> Address QZ 5 RArr G Wd . City Kir rrcjr d zip 9 t{'n J <br /> Phone # ( 510 ) a35 [ 393 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping he decontaminated prior to removal? YES [ ] NO �} <br /> b. Identify contractor performing decontamination: <br /> Name TO )S2 M11QI-S-E?5 LU ILA90 ED AS 474M)OUS <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name !- c-K4+ rtSG Hauler Registration # QL 1 9 <br /> Address 7-55 (4KK END City R,CNryLoto Zip 9V60( <br /> Phone No. (sic) ) Z--S5 - 13q3 <br /> Permitted Disposal Site <br /> Page 4 <br />