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1. Is there a contractor's questionnaire on file? NA [ ] YESW NO [J <br /> a) Is the questionnaire enclosed? YES [ ] NO�w <br /> b) Is the current certificate of worker's compensation insurance on file? YES NO [] <br /> C) Does contractor possess a "Hazardous Substance Removal Actions Cert."? NA [ ] YESLl r <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? [ N1 <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Per . <br /> N/pg YES [] NO [] If YES, Permit # <br /> 4. Have tank(s) or piping pending removal leaked in the past? (If yes, list tank #) YES [] N(�;K <br /> 5. What will be the disposition of the tank(s)/piping? <br /> ieV4C;? i Z/c <br /> f�Fi'/ZT> §' Nail/ iiC.oUS'b,�iU£.i <br /> 6. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] Yl�$WNO[] <br /> 7. Decontamination Procedures: <br /> a. Identify contractor performing decontamination <br /> Name <br /> 1.125v:25 7- <br /> Address s City Z27r7i` Zip <br /> Phone No.(�p9 ) <br /> b. Will tank(s) and piping be decontaminated? YE%2T NO [ ] <br /> Q Describe method used to clean tanks) an r iping (If not in contra/ or' file): <br /> d. Describe how rinsate material will be stored on site prior tomanif ting offsite: <br /> / yZT / <br /> TI// !✓ �.vFrfG 5779T/if�6'rLivS'ATE = S7o 6il�SoL/il/L'� <br /> �- <br /> 8. State Registered Hazardous Waste Haulers and Permitted Disposal Facilities. <br /> a. Residual/Hazardous Waste Hauler <br /> Name <br /> Address c3 �� <br /> City c5'0 State Zip <br /> Phone No. ( Hauler Registration # G <br /> Disposal Site c&'4& <br /> Page 4 <br />