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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YESX NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on rile? YESX NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification'? YESX NO [ ] <br />2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES JX NO[ ] <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Ex hon Permit"? <br />N/A [ ] YES [ ] NO [ ] If YES, Permit # V . <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA/D< 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: <br />Name Hauler Registration # 0 -5f 9 <br />c <br />Address /-257-'5- I l/ e -z' City ip J E <br />Phone # (916- ) 3 21 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES -6C NO ( ] <br />b. Identify contractor performing decontamination: <br />Name <br />Address �J/-� rVP►'y<<� city ea4PP <br />Phone No. <br />C. Describe method to be used for decontamination: / <br />4 r AL --s 4 <br />d. Descr22�ibe w rins to material will be stored onsiterior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Nam ' ulerr Registration <br />Address ��� ice' City Zip <br />Phone No. ( DL <br />Permitted Disposal Site <br />Page 4 <br />