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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 NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification'? YE&Lpd NO [ ] <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES [ ] NO [ ] <br /> 3. Hasa licant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br /> N/A YES [ ] NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA/YES[ ] NO[ ]/ <br /> S. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO.YI <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. q/A <br /> Name Hauler Registration # <br /> Address City Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedures: / <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO11 <br /> b. Identify contractor performing decontamination: / <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />