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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification^? YES • NO [ j <br /> 2. Has a 'Site Health &Safety Plan' for this job site been submitted? �jl �f. 161-b b YES NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit? <br /> N/A YES [ j NO [ ] If YES, Permit # }� <br /> 4. Has the contractor obtained approval from the local fire department to perk offQ�iuf in . NA[ j YE ANO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [X <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name Fnw�S LC.n/✓/ern/YY)Q't/ }L Hauler Registration <br /> Address J,<1 5- �L7N A VOL S,914M city Irl.S.EKTa zip ZS-62Z <br /> Phone # (I/A ) '3-7 / —2-+x`70 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YESk NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name 1 w i TSS n lf�'fl�n I fYC_ L�Fi4l UI OCrtrt <br /> Address at A) City PR4(ZVIUC-2Zip 7q-5-1-12 <br /> Phone No.( �-7 Z-^ 'y/ OC7 <br /> e. Describe method to be used for decontamination: <br /> 'TT7 . n L�--- fzlrtl Sen/ <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> tr -ctA r- /Sy/4c Ar"--tQ7 A1170 77`M// -Q,70= <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name ���I; (7 Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />