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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YESH NO[] <br />(b) Is the current certificate of worker's compensation insurance on file? YES R NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES 14 NO [ ] <br />(d) Has everyone on site, including cranelbackhoe operator, been certified <br />to work on hazardous waste site In accordance with CCR Title 8? YES14 NO[] <br />2. Hasa "Site Health & Safety Plan" for this job site been submitted? YES [f NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA big YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? N#YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) andlor piping? of yes, please explain) YES [ ] N0)4 <br />6. If tank residual exists, Identify transporting hazardous waste hauler: <br />e. ~ Name C U `l 6111 1 c 6 r"'A- al Hauler Registration # (s <br />Vv' {!n }�i Address dv W. I e0 Kd City /� ZtP�� Ei <br />Phone#( <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES t�/NO [ ] <br />b. Identify contractor performing decontamination: <br />Name Vic., M r U <br />Address 12 1 � , ` 411 fs-�' city M 0 d C,sa N zip G 5351 <br />Phone No{ a0 q ) 5 Z q(DS <br />C. Describe method to qe used for decontamination: a h h <br />(lu w., s va i tin`11 be �c \ inSe 0.E IB0 S n 1T,iJ VDIUA�� <br />pre55ur � � her I � IrsF nnk ai I i nc .}ht ute o � � �Ar�,rc�da6f ► c�ekr�e-�,f <br />d. Describe how rhtsate material wll} be stored onsite prior to manifesting offsite: I I h <br />i Kti �\ nS a V M o.k s, 1 wal ne �c k O.t S A e t •) `1t 01- 55 l <br />r0 cio- .a 1 <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name 17 ShU r t4 A V I S ony\ a\jvi (N1 Hauler Registration 9 O( <br />Address I O b V, 1 O 1 ( b 9,D0. A city(ft l� Zip Q S 3 7 � <br />Phoue No. (%,Q � <br />Permitted Disposal Site V K an:Db A IAM 15V A D R ) ('A AP N'4 CA <br />EH 23 046 (Revised 08113199) Page 4 <br />