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• <br />1. t <br />(a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />YES K <br />NO [ ] <br />a'' <br />(b) Is the current certificate of workers compensation insurance on file? <br />YES m <br />NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification'? <br />YES 4t] <br />NO [ ] <br />2..*-, <br />Has a 'Site Health & Safety Plan' for this job site been submitted? <br />YES [ ] <br />NO <br />3.+ <br />Hasap licant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A I YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA [pQ YES [ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [A <br />6.+ If tank residual exists, identify transporting hazardous waste hauler: <br />NameD��t,j�-' /yt �iC�c-� Hauler Registration # <br />Address,, ,,�/ s r� cityy�,e <br />Phone # <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES 4d NO [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />Address ftyp 644a�tla y� City �A' dOAt A;t b— Zip <br />Phone No.(V L —;Z 1,AV <br />C. Describe method to be used for <br />A % _ <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e.* Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name�4�.e '� �=�ias �N G, Hauler Registration # <br />Address �_ City Zip_ <br />Phone No. ( W ) q2 Z ZG 2 rr <br />Permitted Disposal Site <br />Page 4 <br />