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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />3. <br />4. <br />5. <br />6. <br />7. <br />YES/ NO [ I <br />YES j I NO <br />YES;? NO [ [ <br />YES � NO [ ) <br />YES ;,� NO [ I <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A 1< YES [ I NO I I If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA/YESI I NOf I <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I I NO / <br />If tank residual exists, identify transporting hazardous waste hauler: <br />NamekgLIC A <br />VMtiLJEWI Hauler Registration # �749 <br />Addressjb� D EV City 0!-141I �,Zip 153 15 <br />Phone #( Tb -p ) 732 -!p4 -I5 <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES,[/( NO[ I <br />b. Identify contractor performing decontamination: <br />Name W L TVSL 6-eD-TELRYI 1` - u P P E a <br />Address k)6-1)-14 C)LJE: City vRV-0-AUZip L15361 <br />Phone No.(30 ) 3'1 I t.1 r-',.-) <br />C. Describe method to be used <br />d. Describe how rinsate material will be stored onsite prior to mawfest ing offsite• <br />.m GTVQe.ltF 1L Vt Mnr.sm _ - M+- P1ar,D t.)l LL <br />e. Rinsate Hauler and ppeermiittte,,d� Treatment', Storage <br />� && Disposal <br />Facility: 1, l <br />Hauler Name _/ Q7Y'ZRIclo7�1-t.� QhLLO _ ? W � Ck! auler Regiast�ration # 37 4 'I <br />Address 10 63 Civ ��� City MW I M Zip IS 3 11 <br />Phone No. <br />Permitted 1 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />