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0 <br /> 1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES [lj/ NO [ j <br /> (b) Is the current certificate of worker's compensation insurance on rile? YES NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removd Certification" YES NO [ 1 <br /> 2. Has a 'Site Health &Safety Plan' for this job site been submitted? YES NO f ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Gradingand Excavation PermitN <br /> '? <br /> N/A [% <br /> YES [ ] NO [ j H YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ 9'YES[ ] NO[ ] <br /> zz. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. I <br /> Name Anmericpan VQ11£yCnyiorCriDl1w Harder Re&tration # 660/a115-q <br /> Address a_13b city TUVId(IL Zip q,j382t <br /> Phone # ( w ) qlG- 4 45, <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES Vj' NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name rnPjY �X fa Yxl i a The <br /> Address Qram �7� n�/'/� city �p� Zip <br /> o(f/ 1 �15�JI ul <br /> Phone No.( ) 5qp—d- q / <br /> C. Describe method to be used for decontamination: <br /> :fpLk5 il)111 Lap, +ri p. rimxd 3bIhep (4 �rV I'�{1y� 1 <br /> d. Des0be how Ansate material will be stored onsite orlor to manifesting offsite: <br /> 55 40116n drums 12ILLEA. 1nn4=;Pr+yam 1. P(CKecl (.Lp. <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Ame-yfaAri UQ 112V Ln)IiYDMffF ihaulerRegistration # CK)L 6061r� 115y <br /> Address A93(D ('eer fid, city TOCK. Zlp g538a <br /> Phone No. ( W ) q;2- qb 05 <br /> Permitted Disposal Site PI�� Y1 rl QI �f1C, <br /> Page 4 <br />