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it LA.--a LA_+ <br />�. (a) Is there a PHS-EHD contractor's questionnaire on f;EenG EIVED YFS-f-]`ys NO [ ) <br /> (b) Is the current certif tate of worker's compensation insvran" 64.11996 YES,F Y"NO ( I <br /> (c) Does the contractor possess a 'Haessndoas Snbstan�g r ' F�I LTH ANO [ ] <br /> PERMIT / SERVIIES YF <br /> Z. Has a 'Site Health do Safety Plan' for this job site been submitted? YES A[4-'NO [ ] <br /> 3 Has applicant performing removal in the City of Tracy obtained a 'Grading and M=vadou Permit ! <br /> MAN YES [ ] NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YESV No( ] <br /> S. 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: CP) ) On q q b ro 3 q Z <br /> �Name Hauler Registration # <br /> Address S G�r�s' �cl City. AC�c�vk&V'_0 C;� Zip Q 90 <br /> Phone # l a ? 213 S - <br /> Decanfaminatimt Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? TS NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name �` _ ��•��-��� �4ti t'o �+-� u w 1-rte SStS E <br /> Address Z�� �'r-r Zip � <br /> Phone No. (D Z'� - <br /> C. Describe method to be used for decontamination: r 1 <br /> 11� t.v 4 <br /> d. Describe how rinsate material will be stored onsite prior to ifesting offsite: <br /> W L( <br /> e\� Rinsate auler and permitted Treatment;,,�Storage & Disposal Facility. <br /> puler NamU\t-�U r OA) Hauler Registration # <br /> 5 <br /> Address 3 a . 3 City_4- P—r s zip Q !�'3 b 3 <br />• Phone No. ( 2_0 C } 4 Z 7(47 <br /> Permitted Disposal Site3 ��-7 2-1 <br /> Page 4 <br />