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1. (a) Is there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? YES ( NO [ J <br />(b) Is the current certificate of worker's compensation insurance on Elle? YES NO [ J <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ ] <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES [ ] <br />i <br />i <br />2. Has a "Site Health & Safety Plan" for this job site been submitte Q/V -f" GEF* YES NO J <br />N6lA? Gly ��eEiloas AxW&zC S � <br />3. Has applicant performing removal In the City of Tracy o e t"? <br />NIA W YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAM YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tanks) and/or piping? (If yes, please explain) YES [ ] NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Name N 6) R- Gi)'L- [ L Hauler Registration # <br />Address17 D K & 4- City D O N f-! F-- Zip l <br />Phone # ) 610 6 (0 9L— <br />Decontamination <br />Z <br />Decontamination Procedures: <br />Will tank(s) and piping be decontaminated prior to removal? YES')tJ, NO[] <br />b. Identify contractor performing decontamination: <br />Name API/AW-AVD 6Q �rJUL 1)l•(�T7�`L owl <br />Address 400 K3, WlL—�tj u//4tI City 'S1 T7W ZIP 01=17=&c1�?1J� <br />Phone No.( ( ) 44a-7rzG <br />Describe method to be used for decontamination: <br />Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name W12-- Grtt, OIL- - Hauler Registration # 2GGt ( —Z_ <br />Address 0 - �/ L City >OJA-U9 _ Zip 6 Sal Le,LO <br />Phone No. ( ) CO 7— [O627Z <br />Permitted Disposal Site wtv-,T)Zl N2 St'K ULG� Q11,60. ((%M <br />EH 23 046 (Revised 10/19198) Page 4 <br />