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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on rile? YES [yj NO [ ] <br />(c) Does the contractor possess a 'Ha m docs Substance Removal Certification"! YES [yid NO [ ] <br />2. Has a 'Sde Health & Safety Pian' for this job site been submitted? YES [Vr NO [ l <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and FS®vation Permit! <br />N/A W YES [ 7 NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local nm department to perform tank cutting? NAVeYES[ 7 NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (Ir Yes, please explain) YES plr NO [ 7 <br />Ze�ei k), tHU(-loz,LeZ 2 lens- PCove A 14orkey <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name 7-(+ H i -N v r(,N, , A-\ ei c T Hauler Registration # O __33'( <br />Address_"�-;�-o C -L 111' '�)A CityS� Te"CiSco Zip c1''//D7 <br />Phone # ( ,V/ S 1 S Y 3 17,93 r- <br />7. Decontamination Procedures: <br />IL WIII tank(s) and piping be decontaminated prior to removal? YES [4 ---NO [ ] <br />b. Identify contractor performing decontamination <br />Name f/ + fi F(uL) Vc„ 1 Se. - ✓I CcS <br />Address 7-o2G C -k . 1. Rss,v City CAN FZA,,ic;sco Zip gH1O7 <br />Phone No.( 411 1 5-y7- '7{3f - <br />c. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting oRsfte. <br />INYN 32 I �pp� rz RyA-co. cr -ILRUC. <br />e. Rinsate Hauler and permitted T((reatment, Storage & Disposal Facility: <br />Hauler Name H -Y -H 6 rJ vi�oN Me. 1,1 SGQuic s Hauler Registration # 033 <br />Address -1�-O C).+ A gjksYN City SAN F,zaNcL5C0 Zip 10 -7 <br />Phone No. ( /-/ i ( ) ,im� S'7' - <br />Permitted Disposal Site SAnn r A S ap"L- <br />Page 4 <br />