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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES QQ NO [ j <br />(b) Is the current certificate of worker's compensation insurance on file? YES (,d NO ( j <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES k] NO [ j <br />(d) Has everyone on site, including cranelbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES [�'i NO [ ] <br />2. Has a "Site Health & Safety Pian" for this job site been submitted?A,�YES NO [ ] <br />3. Has applicant performing removal in the City ofxZ' obtained a "Grading and Excavation Permit"? <br />N/A YES [ ] NO [ ] If YES, Permit <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAN YES[ ] NO( <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If ves, please explain) YES (] NO <br />6. If tank residual exists, identify_ transporting hazardous waste hauler: <br />NameiHauler Registration Oma'/$ <br />Address CitvZip�21 <br />Phone # ( 2r 5¢_� 3171 " -5-7 �Z 7 <br />a. Will tank(s) and piping be decontaminated prior to removal? YES A NO ( ] <br />b. Identify contractor performing decontamination: <br />NametiC. <br />Address 2'E City Zip FIS <br />Phone No.( 2a <br />C- Describe e --hod to be used, for decontamination: 61r� .c•`x- '• <br />d. De,r ibe how rinsate aterial wi be stor onsitepc 1 to nifes ing offsit <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name . �n^rte �L44,1t" Hauler Registration <br />Address Q© ! Q City(()J.BtMAMizab Zip LISA <br />Phone No. ( T/ ;. ) 3 %J —577 <br />Permitted Disposal Si <br />EH 23 046 (Revised 9/21/96) <br />CAT _ <br />- - rage 4 <br />V <br />