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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 91azardous Substance Removal tion"? YES NOH <br />] <br />(,/ Has a "Site Health & Safely Plan" for this job site been submitted? YES NO[ ] <br />3. Ha",pplicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A YJ YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NO[ ] <br />5. 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: s <br />� wy, PSL 5S 235 <br />Name HaulerRegistration <br />Address 1�� �.'y1 _ City �,Cl (V� Zip® 2.1 <br />Phone # c5jQ ) �3 <br />7. Decontamination ares.' <br />a. Will tank(s) and piping be decontaminatedprior to removal? YES K, NO [ ] <br />, Identify contractorperforming decontamination: <br />Name' ett � '' � ✓�'� Ctr L <br />zip <br />Address&P30—.—Aw,j Pt city (Ar-Lio-j±12 <br />Phone No.(. 1.10 4C. i <br />Describe be used fordecontamination: <br />rR'1 :. ► r <br />d. Describe how rinsate material will be stored onsite priowr to manifesting offsite: <br />kA. e 1 t r r�cTtiMY"9 ^K 1.- G "TTS Ah I A -CV 2/1 ® I G <br />r <br />e. Rinsate.Ilauler—and y <br />Hauler Name pffiR <br />t!55 235 <br />jN(,,Ha.Regisa1o0Y I <br />i �. (01Z I <br />Phone No.Qpi03262 <br />Permitted Disposal Site! I QI ai <br />Page 4 <br />