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1. (a) Is there a PHS-EHD contractor's and subconawtor's questionnaire on file or enclosed? YES W'No( ] <br />(b) Is the current certificate of worker's compensation Insurance on file? YES (j]� 0 [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES (�0 [ ] <br />(d) Has everyone on site, Including cranelbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 87 YES [JINO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES VINO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA (d YES [ ] NO [ ] If YES, Permit N <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[JYES[ I NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES I ] NO V <br />6. If tank residual exists, identify transporting hazardous waste hauler. jjjy� 15DrU1*, / h(o 4-,u 6&1 <br />Name Hauler Registration # <br />0;1_ <br />EH 23 046 (Revised 10119198) Page 4 <br />Address <br />City Zip <br />Phone B <br />Decontamination Procedures: <br />a. <br />Will tank(s) and piping be decontaminated prior to removal? -pip) (1.C1 YES W-10 [ ] <br />JJ <br />b. <br />Identify contractor performing decontamination: <br />��,,'' <br />Name Poi I /- Fy nn l tLLh 1CI lX/ <br />r <br />COL, <br />Address C o Y1 5 � <br />city {Z i him Ztp <br />C. <br />Describe method to be used for decontamination: <br />�iY101 o ri �'n o f-C1.Ul�S <br />d. <br />Describe how tinsate material will be stored onsite prior to manifesting offsite: <br />/(Y/-7 <br />-Mix reIV" fiam hotL, c /ii <br />and /-s leca6Y lo LLtb eA <br />�Q�1K (106) iVlf LP tl ixo r1lbP 1' d-Ld <br />f0 he& i t7 fct- <br />Ce / <br />Rlnsate Hauler and permitted Treatment, Storage & Disposal Facility: y/9- I& �Q V� <br />/' <br />Hauler Name /�%7]//J/,(1Q^(� Cj') ��}�/fy](pyltY�l <br />Halder Registration M <br />Address <br />city ZIP i538�i <br />Phone No.,32'—_L��/�`J' <br />,( / <br />Permitted Disposal Site f� / c� cc l U I [ <br />/ n <br />Lei C# <br />EH 23 046 (Revised 10119198) Page 4 <br />