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1. (a) Is there a PHS-SBD eontnactars and syheuutr toes questionnaire cu file or euciused? YES[] , NO(1}� j <br /> (b) is the current certitleate of Wadmes campmeattoa insuramm an file? YEs[.I' NO[I A . A C C c <br /> (C) Does the contractor possess a'Ha=doas Substance Removal Certification ? YES[yj NO I l <br /> (d) Has everyone on Site,lnchu ding cranelbackboe operator',been certified <br /> to work on hazardous Waste stte in accordance with CCR Title S? YEs[� NO[] <br /> 2 Has a site Heaifh&Safety Plan'for this lob site been submitted? YES M N6 I l <br /> 3 Has applicant performing removal in the City of Tracy obtained a'Grading and E=Vad a Permlt"T <br /> NIA(4-� YES I I NO[I if YES. Permit# <br /> 4. Has the contractor obtained approval tram the Wal tire department to perform tank cutting?nlf q I Nen / <br /> 5. is there Rowledge or evidence of leakage from the rank(s)audior piping? (If yes.pieaSa explain)YES[I NO iy <br /> 6. if tank residnai exists.Identify transporting hazardous waste hauler F-(vx Vj rc]wk S <br /> Name % Haalar Begfzu-4ou# <br /> Address j City Zip <br /> Phone# -' ) <br /> i. Decontamination?roeedurm <br /> a. Will to 93)and piping be decontaminated Attar to removal? MK NO[I <br /> b. Identify contractor performing deeentamLnadan- <br /> Same ( 7vAC.O'+ C a��t l2irh� �t�, • ,-\ <br /> Addrasa 31 C1 La,ktik em e De- my W r qaCiO zip�S <br /> Phone.4@4 G <br /> G Describe magod to be used for decorta�ation <br /> I Describe how dnsate tuaoedaf Will be stareo aitole prior to mandesting atffitw <br /> R rnC r`v�2ev�uner` 2911 <br /> 1151 Is- �o R ,Q,Sa�Zo <br /> �P (la I — 2570 AG ilC 1c- <br /> a Rtnsate Hasler sad petm>tted Treatment&uragepp&Dtsposai FadAtr- <br /> Hauler Name-rd Mo> �:0,0t RO h k e Regtshatinn d C l Q <br /> Ad&= �CLJ-k IZkvek- 1481 tats V3' C acfy ?ap (tS <br /> Phrme,U (b 1 2.570 <br /> Permitted D qwW SBa ���t i��C S W' `1 RC Y1 n1 e•��� <br /> EH 23 046 (Revised IDlf9 M Page 4 <br />