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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including cranetbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? <br />3. <br />4. <br />5. <br />YES 1 1 NO I J <br />YES[] NO[] <br />YES P4 NO [ ] <br />YES D� NO [ ] <br />YES[] NO[] <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A g YES [ ] NO [ ] If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA)Q YES[ J NOJ ] <br />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: <br />Name Pr1407F �L6%!gI a4 -4-r6 1 Cl~M64 Hauler Registration # `tet <br />Address 'Ktv I 4vu+, &-t AA • City� 140 Zip g59 -AK <br />Phone # ( g1to ) 4-L-7-- -; p 1 s- <br />7. <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES )4 NO [ J <br />b. Identify contractor performing decontamination: <br />Name <br />Address 4s' W 1owh f)Zr &"h4- City '5&'-V+ Zip �ISSrL$ <br />Phone No.( ally ) 1-f L?--'ls ZY <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />e. Ringate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name 140 b4V `Lw� t�-Ge r �+1 L 14A,,1­C1Gk- Hauler Registration # P 3 <br />Address�fsl¢ I g0k,h�C-�Ya-k- d t -k- A4 . City Zip `Jon <br />Phone No.( <br />Permitted Disposal Site <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />