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(a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES K NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br />(c) Does the contractor possess a us Substance Removal Certification"? YES 4t] NO [ ] <br />2.,V Has a 'Site Health & Safety ' for this job site been submitted? YES [ ] NO <br />3.4. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A JK YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[A YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [0 <br />6.+ If tank residual exists, identify transporting hazardous waste hauler. <br />Name,- �s�.[u..c Hauler Registration # <br />AddressLc� >� City <br />Phone # <br />7. Decontamination <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br />b. Identify contractor performing decontamination: <br />Name 04 9 di <br />Address &V0 CitySAd04Ma;1b7 Zip..-J,5,g?,2 <br />Phone , <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />A A S yrs ./ .. aJ.0 4,0 ..7�--14 <br />AP11 4 dpi AA <br />e.* Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name s ��,GAa Hauler Registration # <br />Address ��Oy /_ City Zip SMONS <br />Phone No. _J 5f Z Z - ZG Z is <br />Permitted Disposal Site <br />Page 4 <br />