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1. <br />2 <br />3. <br />4. <br />(a) Is there a PHS -EEM contractor's questionnaire on rile or enclosed? YES NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on rile? YES 1 NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification'! YFS r�( NO [ ] <br />Has a 'Site Health & Safety Plan' for this job site been submitted? YES [ ] NO J <br />Has ap [cant performing removal in the City of Tracy obtained a 'Gtadiog and Excavation Permit! <br />N/AYES [ ] NO [ ] If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAV.YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If ves, please explain) YEsy NO [ ] <br />I <br />6. If tank residual exists, identify nsporting hazardous waste hauler. <br />Name Hauler Reb sti tion # <br />Address City Zip_ <br />Phone # <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NOlzi— <br />b. Identify contractor performing decontamination: <br />Name <br />Address Cit' 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 />PhoneNo. <br />Permitted Disposal <br />Page 4 <br />