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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES Ll --No [ J <br />(b) Is the current certificate of worker's compensation insurance on file? YES P- NO [ J <br />(c) Does the contractor possess a 'Haardoos Sobstmaw Remand C rtWcx UouR YES [G)/NO [ 1 <br />2. Has a 'Site Heath A: Satdy Pian' for this Job site been submitted? YES " NO I 1 <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A ( ] YES I J NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] N014-� <br />S. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [ ] <br />6. H tank residual exists, identify transporting hazardous waste hauler. z <br />Name R . C Pa���/ Son/ Hauulferr Registration # t <br />Address_ l 3�q3 l Q/Vp. ivy/ �� City a l v' J� Zip 96;36-3 <br />Phone # ( 2V / ) <br />7. Decontomimfbn Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [4]' NO [ ] <br />b. Identify contractor performing decontamination: <br />Name M J. CST ( C <br />Address P 0 Noy 77 4 7 City FRES NO Zip 43737 <br />Phone No.(26 4 ) 14S6 (.i O oo <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 i (nE- C V t ! N Q 1 Ai Hauler Registration # <br />Address City 7 N 775PS u Zip <br />Phone No. ( 1 <br />Permitted Disposal <br />Page 4 <br />