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1. (a) Is there a PHS-E31D mntracmes questionnaire on file or enclosed? YES M NO ( ] <br /> (b) Is the current certificate of work-er's compensation insurance on file? YES <br /> Sole P,roQrick-do.% \ t <br /> (c) Does the contractor possess a 'Hazardous Substimm Removal Cerdficatiou'? YES pQ NO I ] <br /> 2. Has a 'Sitz Health & Safety Plan' for this job site been submitted? YES r* NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Ekavatiou Permit! <br /> N/A DQ YES [ I NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I ] NO (1t] <br /> IV <br /> /✓ <br /> 11M�Jlfa <br /> 6. If tank residual exists, identify transporting hazardous waste hauler- <br /> Name <br /> aulerName 'Etlylt2�(- IuE-s�"- (SEC po,.lt.uWJ Hauler Registration <br /> Address 13331 N. FtvJY 33 city -AIASotJ zip 953 0 3 <br /> Phone # ( �O() ).Q-7 <br /> 7. Decontamination Procedures <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES Dq NO [ ] <br /> 1� �e55ecs5(> � <br /> b. Identify contractor performing decontamination: 1 I <br /> Name 1�6r l u n� Al/I�A - � eck Cnecri", 11 fnSKf�1�6,T� <br /> Address !b (0 21 0 Ir re- buwc City �� ,,ASr— zip <br /> Phone No.( 20 9 1 %z jn - 87 57 <br /> C. Describe method to be used for decontamination: <br /> Ito. Oq <br /> T�'PIP �iN« wrt'(� �..(• w�-a..t <br /> L <br /> d. Describe how rinsate material will be stored onsite prior tin <br /> or to manifesting offsite: <br /> Tl.c. ri..e.si-� yyw-vti'' .k ,,;[\ V 5t3D tr 1L 77.0 <br /> 569t40.-i dlruaaS ctit•k 0.�tT'oam��'� \ale�\tna A .r• •nte, a nt _ <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name ENg1RODtlY West 1p"LtAsalHauler Registration # <br /> Address 1 -3-331 N. 4kj�• 33 city Pe-We- sotJ zip 953to3 <br /> Phone No. ( 900 ) r47`i - c}t[.4 <br /> Permitted Disposal Site -5:ow tl - . <br /> Page 4 <br />