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E� <br /> SENT BY:Xerox Telecopier 7021 ; 1 94 ; 9:02AM ; <br /> 9163611622;# 5 <br /> I. a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO( ) <br /> YK <br /> b) Is the current certificate of worker's compensation insurance on file? <br /> YES:C)q NO [ ] <br /> 0 Does the contractor possess a "Hazardous Substance Removal Certification"? YES}Cd N® [ , <br /> 2. Has a "Site health & Safety PIan" for this job*site been submitted? YES)tX] NO j ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A[x1 YES ( J NO [ ] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local firs department to perform tank cutting? <br /> NA [X] YES [ ] NO [ ] <br /> S. Is then knowledge or evidence of leakage from the tank(s)and/or piping? YES yes,please explain) No.see Annendix C [ ] NO [X] <br /> 6. If tank residual exists,idendfy transporting hazardous waste hauler: A. <br /> Name Evergreen ENvironmental Services Hauler Registration # <br /> As6880 Smith Avenue City NewarkZip 94560 <br /> Phone No. 1 800 <br /> ) 972-5284 <br /> 7. Decontamination Procedures: <br /> a. Will tartk(s)and piping be decontaminated prior to removal? YES [ ] KO [X] ` <br /> b. Identify contractor performing decontamination: <br /> Name N/A <br /> Address City Zi <br /> Pbone No. ( 1 <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored on-site prior to manifesting off-site: ' <br /> e. Rinsata Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name _ N/A Hauler Registration # <br /> F; <br /> Address <br /> - City Zip <br /> , <br /> Phone No: •( 1 i <br /> • e a' <br /> Permitted Disposal Site j3 <br /> 4 <br />