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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES-K NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on tile? brei OVCD YES NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification'? YES NO [ ] <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES [ ] NO <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grad'ing and Excavation Permit'? <br /> N/A YES [ I NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAM 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 /> 6. If tank residual exists, Identify transporting hazardous waste hauler. 22 <br /> Name 4DA,1bS zi�JlCE S Hauler Registration # 3 l �/ <br /> AddressY0(n -e. AL0, DID 3( .0/2 city 6aj?D�A zip L2-�S <br /> Phone # 10 521 - 030 <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 T11/� '�� 62_061S <br /> Address TL ( IQ C7R/� /3LV`(�, City C_�OpElo q Zip fOL�IY <br /> Phone No.( 5' 23 -gy3o <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> '�Er(cV'E7 /N T lfi4 8-r�c>d r 7/(LX/( BY H-4CLF.J? T/ ef_GZY <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name PAY-)S _54 1116 E S Hauler Registration # 32-16 <br /> Address 1/0( cc, A&C-OD& &✓I:) city 67WDf A �zip ?02-y <br /> Phone No. ( SIG ) 5z3 _LN30 <br /> Permitted Disposal Site P8r6A)A)olkOcnk) ,2ctn tO-k bNa,4 Si. 12P£ZvO <br /> Page 4 <br />