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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES E] NO() <br /> (b) Is the current certificate of worker's compensation insurance on file? YES{] NO(] <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES(] NO[) <br /> (d) Has everyone on site,including cranelbackhoe operator,been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES H NO[] <br /> 2. Has a"Site Health&Safety Plan" for this Job site been submitted? YES(] NO H <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> NIA 14 YES[] NO(] If YES, Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting?NA[]YES[]NO(] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? (If yes,please explain)YES[] NO W <br /> 6. If tank residual exists,Identify transposing 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 M NO[] <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address City _Zip <br /> Phone No4 ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how Ansate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility. <br /> Hauler Name Hauler Registration# <br /> Address City ZiP <br /> Phone No. <br /> Permitted Disposal Site <br /> EH 23 046 (Revised 10119198) Page 4 <br />