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1. (a) Is there a PHS-EHD contractor's questionnaire on Me or enclosed? YES %k NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES'klf NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification'? YES ] NO [ ] <br /> 2. Has a 'Site Health &Safety Plan'for this job site been submitted? YES,] NO [ I <br /> / 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit" <br /> N/A 1.7 YES [ I NO [ ] If YFS, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NO[ I <br /> S. 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. <br /> Name Hauler Registration # <br /> Address City Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedures <br /> a. Will tank(s) and piping be decontaminated prior to removal'. YES [ ] NO [ <br /> `rgW1K WAS f,6m0YE 0 fay pvJr,&)Q- lr KAs Wiil-� O 11 Lk,L <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be zed for decontamination: <br /> V / / <br /> d. Describe how rinsatematerial will be stored onsite prior to manifesting offsite: <br /> 1 / A <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name I Hauler Regi-t ation # <br /> Address N1 IL- City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />