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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES NO ( ] <br />(b) Is the current certificate of worker's compensation insurance on file? YESNO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ ] <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 NO [ J <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES K NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA g YES[ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? N YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) andlor piping? (If yes, please explain) YES [ J NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name �(j IFS Hauler Registration # <br />Address ��J I®1-�'v� RJL®ll City (taico®► t zip V_o <br />Phone # ( 5-/ d35- — 13 i <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YESg NO [ ] <br />b. Identify contractor performing decontamination: <br />C. <br />d. <br />Name W EAT IF S SDE s / uni (-)/1 <br />Address ( City DL /1_ zip <br />Phone No. SSL/ 7 9JI U <br />Describe how rinsaate jn terial will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />I <br />Hauler Name C—e1AC [,,0(, V L �� A Hauler Registration # �ceJ c� <br />Address V�, City kica® Zip <br />Phone No. (2CL—) 237-13q-3 <br />Permitted Disposal Site <br />EH 23 046 (Revised 08113199) Page 4 <br />