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7-25-19% 8:3AAM FROM p_ 2 <br /> 1. (a) Is theta a PHS-ESLD matraaWs gotsdaun ira an 6k or atclased? / <br /> YES [�J NO [ I <br /> (b) Is the current earddrsb of worker's compcusatlon lusarance oa IWT YES W- NO I I <br /> (c) Does the contrecmr possess a 'Ha:Qdc"Sobalance Raw al Cata melm^ YES &i k—NO I I <br /> 2 Has a 'Site Resift t SW07 Plan'for this Job site been submitke YES I.)--NO I 1 <br /> a Elm,ppjicMt Pulbrm1ug remaval In the City of Tracy obtained a 'Gea®og tad Eaeavatiaa parade? <br /> N/A M YES [ I NO I I ItYE5, Permit # <br /> 0. Has the contractor obtained approvai grow the local Gee depabnent to perfo as tank cumAY? NAV, IS[ I NO[ I <br /> Is tions kwwkdp or nldma of lakate hvw the tanks)and/or piptag? (If yea, paesse upiaiu) YES I:I NO (;fir <br /> o mix <br /> If tank resgdual exists,klawW trawpord"btltardow wash baa[en <br /> Name^ Fc��l.�Sp •• w -r, n ....t <br /> -� �-Ct Haakr]ic6sttatlon dr_GQ#9 <br /> Address Z55 Y c.,r r �'{ � _ CltY � Zip <br /> Phom+iF $ /C� 23�- i HCl 3 <br /> ?. Docoulmallmdols Pea a, / <br /> 0)( a Will tank(s) and PiPbg be davataminated prior to removal? YES <br /> b. Ideutll r contractor performing decontamination: <br /> Name Rai!� <br /> V Addten Cit ZIP <br /> a Phone No.(_ ) <br /> G Describe mcthm to be=M far d - Qa <br /> rc <br /> SGv - • 1 <br /> d Desaft hwAle be EmWW WE ba 700sbd onsite prior is psau[testing QMdte: <br /> l <br /> © e Rfusate Reamer sad pta,sa' llpment,Storage&Dbpoal Fad W. <br /> Hauler Name Haview Reostrudon# <br /> Address City ZIp <br /> Phone No. [ <br /> Permitted Dbpaoal Site <br /> Palted <br />