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1. (a) Is there a PHS-EBD contractor's questionnaire on file or enclosed? YFS# NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES N NO [ ] <br /> (c) Does the contractor possess a 'Hsnardoaa Substance Removal CertI88tion'? YFS' \ NO [ ] <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES 9\ NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Mmavation PermlY? <br /> NIA`[(j YES [ ] NO [ ] If YES, Permit # 1.1 AXV E/J <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAO�YES[ ] NO[ ] <br /> 5. Is there knowledge or evidence or leakage from the tanks) and/or piping? (If yes, please explain) YES [ J NOxJ <br /> A sr yA)Spc�Tinn� e 5JG7r/1 FN NO o4JroaS Sr6,A1S n LC-ARAbF Qt <br /> POET A L A)b2 WERE AI011 06"003 QJQQ zS PQ6S&A)Z'' <br /> I <br /> 6. If tank residual exists, identify transporting harurdous waste hauler- <br /> Name <br /> aulerName PETR()LEUM REG�CLIA16- LOk�01t4TIDAbankrRegistration # 6OSS/4672Ce <br /> Address / 33 1 IV , /INJ V 33 clty2trrc.e.5oA1 Ztp 45363 <br /> Phone # ( SS 0 0 <br /> 7. Decontamination Procedmzse <br /> a. Will tank(s) and piping be decontaminated prior to removal? YESY NO [ I <br /> b. Identify contractor performing decontamination: <br /> NameVl1PSbMr F-AUVIPOA)1-1ENTAL se,eoxees, s-/JG. <br /> Address _Jq 6 I Nze(- L)tEuJ duct��City TRAC�Z- Zip 15376 <br /> Phone No.( -2 '533- 07 2 <br /> C. Describe method to be used for decontamination: <br /> VAcVUM WATE2 (OAVTrtrA)C4 rAj TA1✓k LAlTO _rAA&Ee T12(16k , 21nuc <br /> LA)K IrUTC2.1:02 t,WrTH WA7-cr2 AAJd VAGtIL)M /ltN5.4TE <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> iZCNSArc Lt)ZLL NOT dE 5r2),ecD Onl S.rTr. VACUUM 7-g(1c,(1, <br /> WILL /Z EMOJE RSA)SAre 5 A 411! 4 4�j AS /2.i NSelre r< 12ATc,6 <br /> e, Rinsate Hander and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name 5i9Mf A4 - LT EM 48odr Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />