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• <br /> • � � L M aU �� �N 1'2 Ik G�l a � � a G p G'rCs2An 1 N-�''l7 <br /> 1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YESYES[] NO <br /> NO[][] <br /> (b) Is the current certificate of worker's compensation Insurance on file? [1 <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES[1. NO f[ <br /> (d) Has everyone on site,including cranelbackhoe operator,been certified NO <br /> to work on hazardous waste site In accordance with CCR Title 8? YES 11 I l <br /> 2. Has a"Site Health&Safety Plan"for this Job site been submitted? YES 1] NO[] <br /> 3. Has, ' <br /> applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> Nltxy' YES 1[ NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA(]YES[J NO[I <br /> 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain)YES I J N� <br /> 6. If tank residual exists,identify transporting hazardous waste hauler: Gni [ C�{ <br /> 06547446 <br /> Name[4\Lt.tPS �2kN5Po2Thj'tvn� 'F�-e"7>^t=t= thTi�.gaWerReglshatlonN <br /> I' Address P(2 F61( l �0 City S Mnrr_1N Zip 9so4 6 <br /> Phone#[ q00 [ 32( ^ ( 0 0 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s)and piplug be decontaminated prior to removal? YESXNO(] <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> c. Describe method to be used for decontamination: <br /> I <br /> i <br /> d. Describe how riusate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility. <br /> Hauler Name PT -t- " Hanler Reglah'atlon 0 <br /> I <br /> Address City Zip <br /> Phone No.( ) <br /> Permitted Disposal Site <br /> iEH 23 046 (Revised 08113199) Page 4 <br />