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1. (a) is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES NO[[ <br /> (b) is the current certificate of worker's compensation insurance on file? YES[],r NO]] <br /> (c) Does the contractor possess a"'Hazardous Substance Removal Certification"? YES M NO[] <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[►�NO[] <br /> 3. Hasapplicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> MA[.,]/ YES[] NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA�YES[]NO(] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO <br /> Y <br /> 6. If tank residual exists,identify transporting <br /> 1hazardous waste hauler- <br /> Name <br /> auler1 <br /> Name �� �- A-)LtE� _ Hauler Registration# ��T <br /> Address 10 D—S LATN,� City zip <br /> Phone# 5 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piping be decontaminated prior to removal? YES M/NO[] <br /> b. Identify contractor performing decontamination: <br /> Name_ <br /> Address City zip <br /> ' Phone No.( <br /> C. Describe method to be used for deco tamin on: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting oftsite: <br /> LL' <br /> ' e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name 1 V " Hauler Registration# <br /> Address 161 b3 City M L4j) CA +_zip 1531 <br /> Phone No.( -� <br /> Permitted Disposal Site �Dq�T'�7 O�LLI- L6 j <br /> EH 23 046 (Revised 08/13199) Page 4 <br />