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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YESA NO[J <br /> (b) Is the cuff out certificate of worker's compensation Insurance on file? YES$ NO[J <br /> (c) Does the contractor possess a"Hazardaus Substance Removal Certification"? YES)( NO[J <br /> (d) Has everyone on site,Including cranelbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 8? YES)( NO[J <br /> 2. Has a"site Health&Safety Plan"for this job site been submitted? YESA NO J J <br /> 3. Has applicant performing removal In the City of Tracy obtained a"Grading and Excavation Permit"? K/14 <br /> NIA[i YES[J NO[J If YES, Permit S <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA)(YES[]NO[J <br /> 5. is there knowledge or evidence of leakage from the tank(s)and/or piping? Of Yes,please explain)YES[] N0X <br /> 6. If tank residual exists,Id//entity transporting hazardous waste hauler. <br /> Name Q�/,QMS ��rL/iL'�S HaNerRegletratlonl �2 <br /> Address /,0 A&,4glaCity a /df�,rR 71P OaZ�O <br /> { <br /> Phonefl, <br /> (.�!D 1 ? •S���f� <br /> 7. DecontaminationProcednrea: <br /> L Will tank(s)and piping be decontaminated prior to removal? YES JX NO[] <br /> b. Identify contractor performing decontamination: <br /> Name Adam ✓�l�/t P7 <br /> Address •�/�� Iq�atwd q y� CityCOL 4d�?JvA zip Q qq8 <br /> 1 Phone No.( w i .��M -`T elm 340 <br /> C. Describe method to be used for decontamination: <br /> -fit 1%pe Alas e Ley .fir <br /> d. Describe how Ansate material will be stored nsl[e prior to manlfestln tfslte: <br /> [J/// AV; Xe � <br /> e. Rhrsate Hauler and permitted Treatment,Storage&Disposal Facility. <br /> r <br /> Hauler Name /� Lf/jL1 ?Ar!S Hauler Registration# <br /> Address�/ 4 A lnad,✓,* CIty�,�_Zip MA Vg? <br /> Phone No.(—!5(D <br /> Permitted Disposal Site <br /> EH 23 046 (Revised 08113199) Page 4 <br /> 9 <br />