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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[ 1N0 I I <br /> (b) Is the current certificate of worker's compensation insurance on file? YES VNO[I e-0 P-00d r4-- <br /> (c) Does the contractor possess a"Hazardons Substance Removal Ce tion"? YES NO I 1 5-26'0 16 r Z3 <br /> (d) Has everyone on site,including craue/backhoe operator,been certified <br /> to work on hazardous waste site in accordance with CCR Title S? YES NO[I <br /> 2. Has a"Site Health&Safety Plan"for this Job site been submitted? tDl PP`n9 h-0 S NO[) <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIAV YES[I NO[] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?N S[I NO[I <br /> 5. Is there knowledge or evidence of leakage from the s)and/or piping? Of yes,please explain)YES NO I I <br /> s ;I I 'tl r 51* It La,a.ES <br /> 6. If tank residual exists,identify transporting hazardous waste hauler. <br /> Name i G Y1 V0,11eq 1 I RaiderlegWrationiF 44 <br /> Address 0 City Qi` 1 Zip <br /> 45 <br /> Phone#(_ <j <br /> 7. Decontamination Procedures: <br /> a. Will s)and piping be decontaminated prior to removal? YES NO[I <br /> b. Identify contractor performing decontamination: <br /> I <br /> Name VQ,n it e1\ r0 n I dl L . <br /> Address -7 City Zip <br /> Phone% ''( <br /> C. Describe method to be used fpr decontamination: <br /> Cin <br /> rh <br /> f <br /> d. Describe ho rinsate material will be stored onsit prio tom esti¢ offsite: ff <br /> { b Sr 1 @ d ' <br /> { <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> 3-744 <br /> Hauler Name ► h [A� Hauler Re tient# <br /> Address a , y- 3q6 City ® Vl t Zip <br /> Phone No. t_ ' <br /> Permitted Disposal Site i t r <br /> EH 23 046 (Revised 08/13/99) Page 4 <br />