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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES 41 NO 1 J <br /> (b) Is the current certificate of worker's compensation Insurance on file? YES NO [ J <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification`! YES NO [ J <br /> 2. Has a 'Site Health & Safety Plan' for this Job site been submitted? YES(�1 NO 11 <br /> 3. Tins applicant performing removal In the city of Tracy obtained a 'Grading and K"vallou Permit'? <br /> N/A 6j YES [ [ NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAJ YES[ ] NO[ 1 <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ J NO [] <br /> 6. If tank residual exists, Identify transporting hazardous waste hauler. <br /> Name 20 L aQ n-er lee- ��i iry Hauler Registration <br /> Address /33.3/ I r x _s?-? city Zip <br /> Phone # ( Rid 1 S-7 V— yyyy <br /> 7. Decoutgunins on Procedures <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [t] NO [ ] <br /> b. Identify contractor performing decontominatlom <br /> Name <br /> Address 7,01 fi7aG[J /Wr` Mlle) city f�'ladero\ zip-q,3 63-7 <br /> Phone No.( oy 9358 <br /> C. Describe method to be used for <br /> ldecontamination: / _ <br /> /e �- <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> ® f 1A f"7 <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> IlaulerName 1 o9C -Kt?`C,,i2xi Secgl_Ce__ Hauler Registration *rAflOLE/� , � <br /> Address 136.3 / Yl//w7 ,/33 //`,/// cityP soy zip 953 3 <br /> Phone No. o 977 - `'�7 `? `l <br /> Permitted Disposal Site SCLiM2 <br /> Page 4 <br />