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1. (a) Is there a PHS•EHD contractor's questionnaire on file or enclosed? YES to NO [ ] <br />(b) Is the current certificate of worker's compensation Insurance on rife? YES bi NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal CertlSatton'! YES jd NO [ ] <br />2. Has a 'Site Health & Safety Plan' for this Job site been submitted? YES f4 NO [ ] <br />3. Has aplicant performing removal In the City of Tracy obtained a 'Grading and ExcaPermit'?vation Permit <br />NAA YES [ ] NO H YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] 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. <br />Name/. /7^C - Hauler Registration # <br />Address/Z3 /!ted/�G7 �G✓x,� 33 city F2Te%!�eLl zip <br />Phone # 0% c? <br />7. Decontamination Procedures: <br />a. WIII tank(s) and piping be decontaminated prior to removal? YES M NO ( ] <br />b. Identify contractor performing decontamination: <br />Name 5 - <br />Address <br />Address 22_36Sz�l %al -d city&ee-4"e fi�-e,-,7-zip 9 ZGZo <br />Phone No. 7( ,"f ) 25215e,� <br />C. Describe method to be used for <br />d. Describe howAnsate material will be stored onsite prior to manifesting offsite: <br />/Z r7f P"WJ T/A- <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name /7 L� Hauler Registration # .70 ,�5V2 <br />Address j.�3�3/ lllaith /die �w� 3 city aL6e ��� zlp� <br />Phone No. <br />Permitted Disposal Site E -fl' -G__ 1333 <br />Page 4 <br />