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0 0 <br />1. (a) Is there a PHS-EED contractors questionnaire on Me or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on Me? <br />(c) Does the contractor possess a "Hazardous Substance Remand Certification'? <br />2. Has a 'Ste Health & SaW Plan' for this job site been submitted? <br />-* f3EiNG Ski WNC Sr?aJtA—, t C011VL <br />YES Of NO [ ] <br />YFSN NO[] <br />YES NO [ ] <br />YES [ NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />NIA -K 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 />S. U 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 harardous waste hauler. <br />Name A F, Hauler Registration #2 <br />Address 1 rJ L, City. M A4 CZp, Zip_ 2✓� 3 Q� <br />Phone # ( Zo C ) :o c � - %O I <br />7. Decontamioa ion Pracedmes: <br />R. VVM tank(s) and piping be decontaminated prior to removal? YES tX NO I ] <br />b. Identity contractor performing decontamination: <br />Name <br />Address 3 1 510?J city ks)PA/1- Zip Cl3b3S <br />Phone No.( 14� ) lV to \ — 7� 1 <br />C. Descr! method to be used for decontamination <br />1 W AT%SL W 17-41 Kt- —(0 Y-1 L ��-rF,nc�,,,�T ( r s P) <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />�.�LilJw� 'T2J(.1L <br />e Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: q <br />Hauler Name I1 • T n q Hauler Registration <br />Address �J15�3 I JI . l City 1' \A-rJF. A Zip <br />Phone No. ( 20'1 ) (.0 1P <br />Permitted Disposal Site P�TQ D . ( FIN 00 t -f <br />Page 4 <br />