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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on rile? <br />(c) Does the contractor possess a Maardoua Substance R � )� cettionR`��� <br />2. Has a 'Site Health do Safety Plan' for this job site been sub [ted Wache' <br />3. <br />YES [�f NO [ ] <br />YES [+1 NO [ ] <br />YES [q NO [ ] <br />YES [d NO [ ] <br />Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit*? <br />N/A (.K YES [ ] NO [ ] RYES, Permit # <br />4. Has the contractor obtained approval from the local fire depa en to erfo k cutting? NA[ •] [ ] NO[ y <br />-� bp - w IT nau%e a5 hazes- a�.�� <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 residua�exists, identify transporting hazardous waste hauler, p <br />Name �� �✓(?%j i5� IiiO/V P� 5711 ZE % Hauler Registration # /���� 0 <br />Address/, �GGI i �71C1%� ,��,�4 city . zip 75 <br />Phone # ( qlu ) J / l ` -5 A -Z 1 <br />7. Decontamination Procedures <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [.jam NO [ ] <br />b. IdentifJy'°ntractor performing decontamination: <br />Name /Yl// ( %I { 1 A4L. <br />Address ��7�n� / �Ol% MMCC V(i city J( zip 7 6),?% <br />Phone No.( "Il y ) -37.x- 7535 <br />C. _Pescribe met to be usedor decontamination: <br />t�j 2 <br />l�-Iholwaklzi olpa a_ 'i�Pperr� ��clutic <br />d. Pescribe how rins to material will be stored onsite prior to manifesting olf IT <br />WIMijUI <br />.�/mrJipM r�. rj,cp�l� tl/2(s7zS c,- J/a(u1lr�P�� l�r��!/U /refs <br />M1 4"1 <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal racility: <br />Hauler Name G' 1 I /u` Harder Registration # �J f <br />� l <br />Address 1515 city ?. zip <br />Phone No. <br />Permitted <br />Disposal Site G �% + M� ` f <br />g 4 <br />