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12-10-1998 3 : 39Pt 1 F101 <br />1. (a) Is there a PHS-EHD contractor's andAbcontractor's questionnaire on file or enclosed? <br />(b) Is the current cerUDcate of workers compensation Insurance on file? <br />(c) Does the contractor possess a "fl ons Substance Removal Certification"? <br />(d) Has everyone on site, Including cranalbackhoe operator, been certified <br />to work on hazardous waste site In accordance with CCR Title 8? <br />2. <br />3. <br />4. <br />5. <br />FA <br />Sas a "Site Health & Safety Piano for tWs job site been submitted? <br />Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA (j FES { j Noll If YES, Permit # <br />YES(I NO <br />YES(] No <br />YESg NO { I <br />YES'W Noll <br />YE NO)I <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA{ I YES( j Nope <br />Is there knowledge or evidence of leakage from the s) and/or piping? (If yes. please explain) YES { j NO <br />If tank residual exists, Identify transporting hazardous waste hauler., <br />NameC®Ly�T-a�rnG�.. <br />P. 4 <br />Hauler Registration# <br />Address /3'73$ J/Qe4--,Z, 44/E city .ter .9 ZIP- 92632 <br />Phone # Ll. °� 1 .355- $6D 1 � M <br />Decontamination Procedures: <br />a. Will tanks) and piping be decontaminated prior to removal? YES NO { j <br />b. Identify contractor performing decontamination: <br />Narne <br />Address& SLnn�.� �y� -- ci>nY „r,,✓9 zip 92337 <br />Phone Noy 94 9 _ —}_ •365 <br />C. describe method used for decors tion. <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />`r. Rinsate Hauler and l i it ' 1 Treatment, Storage . Disposal <br />HaulerName ♦aWer Registration �. <br />A i r .. . i C i S it i.. zip r <br />V/Permitted Disposal Site - <br />EH 23 046 fRevised 101191981 Pave 4 <br />