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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO [ J <br /> (c) Does the contractor possess a "Hazardons Substance Removal Certification"? YES ].� NO [ ] <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES [�[. NO [ ] <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES ], NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A [ ] YES`{ ] NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NO]� <br /> 5. Is there knowledge or evidence of leakage from the tanks) and/or piping? (/If yes, please explain) YES [ ] NO [ ] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: /'1�(/ <br /> Name p t. 1 rlC� Hauler Registrrtion # LqOiRY03e <br /> Address �� P.t,E- �rc�C' • S[ City Zip 9 02bc&- 30'4a <br /> Phone 0 '2 l R 8�, <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br /> b. Identify contractor performing decontamination: n <br /> Address ���� h'T\Nv+ a A(r �f��L City --7A�Lr_� Zip <br /> Phone No.( Q c) <br /> C. Describe method to be us econtaminatfon: <br /> d. Descri,�be how ' sate materia wtll be stored onsite prior to manifesting offsite: <br /> )�x <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> � �1( <br /> Hauler YameljR`u!(,l) �—Af'(Lh—� Haalcr Registration #� <br /> Address ��.4`l k L a--t.� %.p City �Y�L-�-- Zip <br /> Phone No. ( <706 3 Z I —16,5 Q <br /> Permitted Disposal Site <br /> 5i:0 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />