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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES p( NO[] <br /> (b) Is the current certificate of worker's compensation Insurance on file? YES)j NO[] <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES Pt 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 p( NO[I <br /> 2. Has a"Site Health&Safety Plan"for this Job site been submitted? YES K NO[] <br /> S. Has applicant performing removal In the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA K YES I] NO[I If YES, Permit N <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NARYES[I Nox <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? Of yes,please explain)YES[] NO <br /> 6. If tank residual exists,Identify transporting hazardous waste hauler. <br /> Name ) "/I/ii Hauler Registration if <br /> Address &IV A C n'A ZIP Q <br /> Phone x(_3 /D ) —6023 - 44AC <br /> 7. DeeontnminationProcedums: <br /> S.- WIH tank(s)and piping be decontaminated prior to removal? YES K NO[] <br /> ! b. Identitycontmettorperformingdecontaminadon: <br /> Name <br /> Address—n'/,04o L'� A IO Na(2A B a city i9ftQ4w,9 zip 40-?14 Y <br /> Phone No.(3/Q )—.5.2 3 •hq4l3D <br /> C. Describe method to be used for decontamination: <br /> d- Describe how rinsate materia will be stored onsite prior to manifesting offsite: <br /> 5-5- - q -Aiy e I S <br /> ErAWL.5 <br /> e. Riasate Hauler and permitted Treatment,Storage&Disposal Facility. <br /> Hauler Name / 4/ wA/S nAe l%l ie f S Hauler Registration s p <br /> Address /�-l�'70& e . IV ALaltA- City� �� <br /> LZIP gaAfi( p <br /> Phoue No.(--S /D <br /> i <br /> Permitted Disposal Site <br /> JEH23046 (RevlsedOW13199) Page <br />