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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES A NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br />(c) Does the contractor possess a Substance Removal Ccrtifleation"? YES NO[ ] <br />2. Has a 'Site Health & Safety Plan" for this job site been submitted? YES jib, NO [ J <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A YES [ ] NO [I If YES, Permit <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA*,YES[ ] NO[ ] <br />S. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] N <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name (- I r� 1 C u L r on r .,o J G f o v I, HaulerR tration # <br />U g <br />Address Z -�j � l I n� A z n v e City C M Zip — <br />Phone ( E,D -3�- <br />7. DecontaminationProcedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YESA NO [ ] <br />b. Identify contractor performing decontaminatioCn: <br />Name �e��e� Cnvcronmcr�41 �r�vdc� j <br />Address L41MsldDrtv City _11 Sk2v zip �0/ <br />Phone No.( 5 i� 2-2910 <br />C. Describe method to be used for decontamination: <br />Tr <br />d. Describe how rinsate material Vill be stored onsite poor ttpp manifesting offsite: <br />UJM be slbieV toyacouw% truck <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name F! �S ` au ronMP,'-W LOU T_ Hauler Registration #1,61;- <br />Address s0� (nS AUenyC city woo' zip b <br />Phone No. ( 510 ) 232-Q) 0.1 <br />Permitted Disposal <br />G"LvA_ envdrdnr^e4 , q <br />Page 4 <br />ec� <br />