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�r J <br /> i 1. (a) Is there a PHS-EIDJ contractor's questionnaire on Gle or enclosed? YES W 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 jkf NO [ ] <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES NO [ I <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit? <br /> N/A X YES [ ] NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAArYES[ ] NO[ ] <br /> S. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain)//``YES ( ] NO�C] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name 1�6L(e>7 /E72aGCu,,? Hauler Registration # / S$ <br /> Address �0, 1gaf l93 City /7IOOE570 Zip 9S35Z <br /> Phone # Z( Ol ) 57 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YESe 'r NO [ I <br /> b. Identify contractor performing decontamination: <br /> Name 5�/11Gp <br /> Address l2/� WTe -?fy 9'7-A E7 City Zip <br /> Phone No.( Z09 ) 5-zevl 9653 <br /> C. Describe method to be used for decontamination: <br /> THE Ttiq &/D l/toiiG6 !wic ge 7z1PGE e/N5GD t T- /f30'a!;14"4 -�- GOw <br /> QO lell CPASArA, 71YEG1R NSE t,64"iAE 6 C/S 01C <br /> A /oD�6 DEASLE OET ebur 7-At Tao .vqc RovSES lvicG AF CLE,Y.L 4119z'E2 <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> 7l/47 AV/ <,f7E ,"7*401AL 4yia BE- :;P&i5O OkSnE t,N &71?6- S$ &Auoy <br /> O,tac� S 4117h sVitoI'el-f C 64heL5 <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name <br /> � 1i LL/E14 AF7/Z06,54/,/ Hader Registration # //sg <br /> Address 110, A0. ' /95 City XCOESTb Zip 95352 <br /> Phone No. Og ) ✓��6 rJJ��O <br /> Permitted Disposal Site �EF/NERy .S6,CdIGES ��T6Qs0/V, 64 <br /> Page 4 <br />