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I, (a) Is there aPHS-EHD contractor's questionnaire on file or enclosed? <br />yES M NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? <br />YES [y] NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification"? YES M NO2. ( ] <br />Has a 'Site Health & Safety Plan' for this job site been submitted? YES (it7 NO ( ] <br />3, Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit'? <br />N/A [A YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAM YES[ ] NO( ] <br />[ ] NO (z]� <br />j. Is there knowledge or evidence of leakage from the tank(s) and/or piping. (If yes, please explain) YES <br />6, If tank residual exists, identify transporting hazardous waste hauler. <br />1\ ) I (� Hauler Registration # <br />Name `�. I_` <br />CityZip <br />Phone # <br />7. Decontamination Procedures: <br />(✓i [ ] <br />a. Will tank(s) and piping be decontaminated prior to removal.o yES NO <br />b. Identify contractor perforating decontamination: <br />.� <br />Name K C <br />u-� "� <br />l_r" Zi <br />Address city I� 1-[� W �ev-w>"- 4-"-P'�— <br />Phone No.( 7 b S ) <br />C. Describe method to be used for decontamination:, ` �t w i v <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: / <br />Hauler Name Hauler Registration # 25 <br />i_ <br />city i <br />Address c Zip �6__ <br />Phone No. 7 H 31 <br />Permitted Disposal Site <br />Page 4 <br />