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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />2. <br />3. <br />4. <br />5. <br />6. <br />YES NO[] <br />YES NO[] <br />YES NO[] <br />YES)( NO[] <br />Has a "Site Health & Safety Plan" for this job site been submitted? YESP NO[] <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A)( YES [ ] NO[] If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAVYES] ] NO[ ] <br />Is there knowledge or evidence of leakage from the tanks) and/or piping? (If yes, please explain) YES NO [ ) <br />.DrA;'N� -- <br />If tank residual exists, identify transporting hazardous waste hauler: <br />Name AMA <br />Address <br />city <br />Phone # C�- <br />7. Decontamination Procedures: <br />a. Will Lttti(s)eftd piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name N A <br />Address City <br />Phone <br />C. Describe method to be used for decontamination: <br />/V/A <br />Hauler Registration # <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />Zip <br />YES [ ] N0)4 <br />Zip <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name &/A _ Hauler Registration #_ <br />Address City Zip <br />Phone No. <br />Permitted Disposal Site <br />EH 23 046 (Revised 08/13199) Page 4 <br />