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w),)&e- C 111 u1 LAI- .�_ tom, <br />1. (a) Is there a PHS-EHD contractor's questionnaire oneno E I V E D YES 4, ] NO [I <br />(b) Is the current certificate of worker's compensation insuran ;;r� �0141�1e9�96 Yom .. -[J NO [ ] <br />(c) Does the contractor possess a 'IIazardoas SnbstanW*jW"&"Fi.F TH S,[-j'''^NO [ ] <br />PERMIT / SERVI��ES <br />2. Has a 'Site Health & Safety Pian' for this job site been submitted? YES 14—NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit"? <br />N/AU YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YESA, NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NOX <br />6. If tank residual exists, Identify transporting hazardous waste hauler. C 44 Cao �3 6 6301ZName L L Sb vt Hauler Registration # <br />Address Ci Cc&c.a Zip Q O <br />Phone # `3 q 13 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES >' NO [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />s-�c,.S <br />� <br />o � . �y.�_ : <br />1 n ll w t +-` �U �a I -O s5e s t <br />�� � t a m t ell <br />' <br />L <br />Address <br />Z�� <br />�af, �- i � <br />City ick -0L.�[ <br />Zip <br />l <br />Phone No. l 2; '13- (11 -3 <br />C. Describe method to be used for decontamination: �I j <br />d. Describe how rinsate material will be stored onsite prior to m nifesting offsite: <br />e. p <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />I U %r - <br />Hauler Registration #, <br />l o <br />Address I 333 ( IUD, 4� . `3`� city ���SG 4� zip 4 S'3b1 <br />Phone No. (22 5 ) 9 ct 2-- E ? L ? <br />Permitted Disposal Site C b ® 631 �)() -7 2'B <br />Page 4 <br />