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I. (a) Is then a PHS-EHD conmactor's gmestionnaln on filis or eneloSed? YES I I NO I ] <br />(b) Is the torrent Geste orworker's compensation insurance on file? YES I ) NO I ] <br />(c) Does the contractor possess a 'Hazardous Substance PEUK"ll Ce.•tidftNon" YES X NO ( I <br />2. Has a 'Site HeaY3 & S&W Pias' tot this Job site been submitted? YES I ) NO [ 1 <br />3. HAS applidut perfo�Xrming removal in the City of Tracy obtained s 'Coding sad )?Xcae 00%t Yermit? <br />NIA I ] YES )"r NO I ] If YM. Permit # <br />d. Has the Contratior obtained apyravai from the local fire department to perform tank cutting? NAWYES[ I NO( ] <br />S. Is there knowledge or evidence of Ieakage from the Wk(g) andlor Piping? (If Yes, please explain) YES I I NOX <br />G If tank residual ad5 <br />5e/s6 identify transporting hazardous waste hauler- <br />iner RCvSLrW— ir ) <br />address ��� t"s��NA y24Sst% jCky a"1c,!;4qzip R4 -1o7 C/ <br />Phone # <br />7. Decontamination Pro"dmzv- <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ I NO)< <br />h. Identify contractor Performing deconmmination: <br />Name <br />Address <br />Phone <br />c. Describe mathod to be used <br />d. I)esxrtbe how rinsate material will be <br />e. Wnsate Hauler and <br />flouter <br />Phone ; ( ? <br />Disposal <br />City <br />tored�ite prior to manifesting OMle' <br />nt, Storage dr Disposal 'airy: <br />H.aaler tion $, <br />Ciq• __ <br />Page 4 <br />