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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES W NO[] <br />(b) Is the current certificate of worker's compensation Insurance on Ne? YES{'NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YESk"O [ ] <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,�rNO ( ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES P -NO ( ] <br />3. Hasa cant performing removal In the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA YES [ ] NO(] It YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? N S[ J NO( ] <br />5. Is there knowledge or evidence of leakage from the tanks) and/or piping? Of yes, please explain) YES [ ] NOW/ <br />6. If tank residual exists, identity transporting hazardous waste hauler. <br />Name Hauler Registration 0 <br />Address City Zip <br />Phone # ( ) <br />Decontamination Procedures: <br />Will s an decontaminated prior to removal? YE NO ( J <br />b. Identify contractor performing decontamination: <br />Name <br />Address —O Z A&- ��/o.cJ � 1 � Cl Zip gS�ZD� <br />Phone No.( D ) Z16 C — U <br />C. <br />GI <br />Describe howrinlate material will be stored ous to prior to manifesting offslte: . <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal FacWty- <br />HaulerNa.4 co�-J VAU�` N/] a4/ &oerRsg1stmtion 7 <br />Address p < Tt�,— CT 1711b City Zip S1 <br />Phone No. / — 416 7 J <br />Permitted Disposal <br />EH 23 046 (Revised 08113199) Page 4 <-14,p ,gyp' 61 /20 <br />" -5-6z <br />