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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES [ ] NO IQ <br />(b) Is the current certificate of wo er's compensation Insurance on rile? YES [ ] NO b4 <br />AMLP w+Da— Z W L'VY17— <br />(c) Does the contractor possess a 'Hazardous substance Removal Crrtification'? YES [ NO [ ] <br />2. Has a 'Site Health d: Safety Plan' for this Job site been submitted? YES 4Q NO I 1 <br />3. Has applicant performing removal In the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A I ] YES I ] NO [A If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NApQ YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NOW <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name N 1A Hauler Registration # <br />— r <br />Address City Zip <br />Phone # <br />7. Decontamimtion Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES 6C] NO [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />& e <br />4 <br />/fit; ]<r E h c/ <br />Address <br />rya G� <br />�m <br />r 3 i�T s-' ! . <br />// <br />City /1'/.1?, P1. J Zip % S O S•� <br />Phone No.( yE' h ) 51 el Z P, ( P <br />C. Describe method to be used for decon urination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Stornge & Disposal Facility: <br />Hauler Name 1 Hauler Regtstratiou # <br />Address City Zip <br />Phone No. <br />Permitted Disposal <br />Page 4 <br />