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11/20/2006 15:27 209468340 <br />Oct 09 06 09:56a Si R Engineering <br />1. <br />7 <br />EHD + PAGE 01 <br />i <br />8186423?60 N•4 <br />(a) is there a EHV cmbt toga • subcont»etox's (questionnaire an file or enclosed? ' [ ] NO OH <br />] ] <br />(b) is the current certificate of worker's compen mtic' assurance on file? �� <br />(c) Does the cmix cho possess a "Hazardous Substance Ramal CertiB" tion"? YFSkJ'� NO ( ] <br />ite including warm/backhoe operator, been certified to work on <br />(d) Has everyorte on s <br />YES NO j ] J. iv 2 jJ a! 7 <br />(e) haardous.+asiesitea+eaordancewithCCKTi�leB? <br />NO <br />Has a'Site Health & Safety Plan" for this job site been submitted? YA;s ,jKZ-w-3.L' <br />�r <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit'? I luJ l�Jo <br />�. �•'!tT,- <br />NO fI if YES, PermitF <br />UA- ci ct^x:t'^nor obta;s_<d Approval from the local ir&e department to perform tank cutting? NA[ ] YES( J NQP- <br />?� ;•• �..r_._;�;,.01+??ge m avidarc.+of !nksge f a .. the, ianR(s) andJor vioim? (N Yes, please explain) YES G) NO., <br />vu.,_v _ j:a.i �m 4etent:ty trznsc_ ^3�-nc %.>fp.r3 �vne W -V?'✓_ hflUlnT: <br />n <br />Name, Hauler Registation N ! 9 <br />fpl�Wt 10i1_YD elu .SC.N7TlOiJlli ZiP5fI!i!l _ <br />guru\a\i9k�on Pnsc?dtxsrvs: <br />Z•d <br />09LE2bB8TB <br />2uivaaut9u3 ,y H <br />JS2:90 90 OZ Aom <br />