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1. (a) Is there a PHS-EHD contractors questionnaire on file or enclosed? Yrs N NO [ ] <br />(b) Is the current certificate of workers compensation Insurance on file? YES P( NO [ ] <br />(c) Does the contractor possess it 'Ilaardous Substance Reamal C riffs ation? YES JQ NO [ ] <br />2. Has a 'Site Health h Safety Plan' for this job site been submitted? YES P( NO [ ] <br />3. figs applicant performing removal In the City or Tracy obtained a 'Grading and Ezcavation Permit? <br />N/A 'K YES [ ] NO [) If YES, Permit # 1✓AtuED . <br />4. Has the contractor obtained approval from the local fire department W perform tank cutting? NA�j(J YES[ ] NO[ ] <br />S. Is there knowledge or evidence or leakage from the tank(s) and/o pipin ? (pCyes, pl N , jai )�/ `�Y`EfS QQ NO [ 1 <br />s.nai! st r� a rpy�ncl wostc v: jJj <br />6. If tank residual e)dsts, identify transporting hazardous waste hauler. <br />Name PE1',1-0L C VM RfcyCl,1' & ZOR4Wafl0, Hauler Registration # EDH ,o4 31W- <br />Address/3�3/ /I%- / kVy Z33 City A-17 Uc on ZIP <br />Phone # ( 900 ) 'E Yi - vZrvy <br />7. Decontamination Procedures: <br />a. VYU tank(s) and piping be decontaminated prior to removal? YFS/( NO [ ] <br />b. Identify contractor performing decontamination: <br />C. <br />d. <br />e. <br />Name NA-r&dr Fi[ t.,zee zzlip- ,4z, LNG <br />Address &J/ 11ra 1/1FA) AJ14,V— City TGV Zip c7S 3 %6 <br />Phone No.( 7 09 ) 4-1-3 - i27t9 <br />Describe method to be used for <br />Describe how rinsate material will be stored onsite prior to manifesting onsite: <br />Rlnsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name hauler Registration # <br />Address <br />Phone No. <br />Permitted Disposal Site <br />Page 4 <br />City <br />Zip <br />c <br />