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0 <br />0 <br />1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES 14' NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES {✓r NO [ [ <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [✓jam NO [ [ <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? YES NO[ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES rf' NO ( ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A [�,j" YES [ ] NO (] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAKYES[ ] NO( ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ I NO V'[ <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Named / Hauler Registration # �r5 <br />Address ���� / JLC City Jk' I ��%►�1��' zip C/ <br />Phone # ( <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />Address � � �� � � City zip <br />Phone No.( '� ) <br />C. Describe method to be used for decontamination: <br />x LE 121 IJP c. A.h.P V,,42 -ZE 1, t2 e I�Ok'_ s <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />%915 }2CO.Sra_G/`/zip/ e -K <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Hauler Registration # 16-33 <br />Address S f4i4 09 9L-V�� City X/4-19),vt zip <br />Phone No. <br />Permitted Disposal Site <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />