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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO [ <br /> (b) Is the current certificate of worker's compensation insurance on file? YES_P{ NO [ I <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES ph( NO [ I <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title S? YES be NO [ J <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES NO [ J <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A YES [ J NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAKYES1 I NO[ 1 <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ I NO}� <br /> 6. If tank residual exists, identify transporting hazardous waste auler: <br /> r� <br /> Name S uler Registr}tion # / J <br /> Address �/( T! 1 !� City 1- ,-,jrh, -" Zip �Vkj <br /> Phone # �t/ � 7 V6 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES X NO [ I <br /> b. Identify contractor performing decontamination: <br /> Name t &ie .Cv�Lr-'��/'� <br /> Address J 7 �r �J Vr City �t't�% Zip <br /> Phone No.( 0 <br /> C. Describe method to be used for decoontamination/:, <br /> /La:..zCi <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> �J <br /> e. Rinsate Hauler and permitted rea(me/nJ},� ito/rage & Djsposal Facility: LLL-A-- <br /> YXi-V-C -, <br /> Hauler Name Hauler Registration # <br /> ` 02/VV Ili . fi X`0— Arz� : � �CJ2ZL <br /> Address J�' qq City Zip <br /> Phone No. ( <br /> Permitted Disposal Site <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />