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I, (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO[ ] <br />(b) Is the current certificate of worker's compensation insurance on rile? (-erJat ) YES C1 NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification"? YES NO [ ] <br />Has a 'Site Health & Safety Plan' for this job site been submitted? ( �Vldtlu ) YES [yJ NO [ ] <br />3, Hasa icant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A @I1 YES [ l NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA [�] YES[ ] NO[ ] <br />g, 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: 8g <br />Name <br />K(C K -J U i Hauler Registration #-I� S U3 <br />�j` �% city F1,L4 M911� Zip <br />Address Z 5-5— GtY"� � cir <br />Phone # (5 ) 35 1 3�3 Q✓t �"T�(� <br />Decontamination Procedures: <br />a, Will tank(s) and piping la be decontaminated prior to removal? I �tn� YES Ell NO [ ] MAn', r <br />iks <br />b. Identify contractor performing decontamination: <br />� <br />Name <br />Address <br />`I. V 10 ( air f city U`� J�CXCEfY`g1� ip t <br />��Phone No.(____--) <br />C. <br />d. <br />Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e, Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: C,40 �0 35S/ <br />Hauler Name,Q'�✓� Hauler Registration # _ �0 <br />is 's C ,,, gy <br />Address CS i t 's P(U e �" City <br />Phone No. ( ) -3-7L-_<0L7- �1�— �s <br />Permitted Disposal Site P( fs s F -6w, ` �10 i �J <br />Page 4 <br />