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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES N NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on tile? YES W NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ NO [ I <br />(d) Has everyone on site, including cranelbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES ( NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES 0( NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A 0 YES I I NO [ I if YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank tatting? NWYES[ I NO[ I <br />5. Is there knowledge or evidence of leakage from the tank(s) andfor piping? (If yes, please explain) YES [ I NOX <br />6. If tank residual exists, Identify transporting hazardous waste hauler: <br />Name li o Hauler Registration # Z4 [� <br />Address C• L & b t City Poiki f L- zip <br />Phone #J <br />Decontamination Procedures: <br />a. Will taak(s) and piping be decontaminated prior to removal? YES QQ NO [ j <br />b. Identify contractor performing decontamination: <br />Name kv*cen Cin- jV1 fjM iaj77V .. /xiG <br />Address N W I L SOA u Cityax <br />Zip lis Z� <br />Phone No.(__ j 67-I00 6 <br />C. Describe method to be used for decontamination: <br />-' R 1P -5 ti I I T74 STEW 6645A7JeTZ-- <br />d. Describe how rinsate material wlll be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility. <br />Hauler Name ,1 Hauler Registration # <br />Address I ^ 0 , F7 &< L0City Da } fg, Zip <br />Phone No. (Ul ) &&-7 —602— <br />Permitted <br />6b2—Permitted Disposal Site -L UG,f�il J (• /G t c r At, <br />EH 23 046 (Revised 10119198) Page 4 <br />