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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification ? YES NO [ ] <br /> Z. Has a *Site Health & Safety Plan' for this job site been submitted? YES NO ( ] <br /> 3. aakagoicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit" <br /> NIA YES ( ] NO ( ] If YES, Permit # ` , <br /> 4. Has the contractor obtained approval from the local fine department to perform tank cutting? NADd YES( ] NO( ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES WINO ( ] <br /> d 7 <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name /yJG. �� r( nIAIG Hauler Registration # �/j/.�65 <br /> Address 710rx�KsldE PL Cit}„SV� ip 17y5-e- <br /> Phone # <br /> 7. Decontamination Promdures: <br /> a. Will mnk(s) and piping be decontaminated prior to removal? YES)( NO [ ] <br /> b. Identify contractor performing decontamination: <br /> NameC�rf�i`/C�i2N�/¢ J�?, �tZS �ie6zj�/ <br /> Address .30p77 .50 1/¢iAoO-.57- Cit7..c�tm9 AivR- Zip ` t <br /> Phone No.( 7/ 1 ) �� - ?4?/6 <br /> c. Describe met od to be used for decontamination: <br /> f�0 `SG� <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> AW 3M- f recwm <br /> I IQy ,vs <br /> e. Rinsate Hauler and permitted <br /> �Treat hent, Stogy/rage & Disposal Facility: <br /> /► <br /> Hauler Name 4g 4k .,ly +�-�' Hauler Registration <br /> � r <br /> Address city zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />