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1. (a) Is there a PHS-E D contractors questionnaire on Me or enclosed? YES# NO [ I <br /> (b) Is the current certificate of worker's compensation insurance on rile? YES N NO [ ] <br /> (c) Does the contractor possess a 'Raardoae Substance Removal Cett6cation-? YES Jti NO [ ] <br /> 2. Has a 'Site Health do Safety Plan' for this job site been submitted? YES NO [ ] <br /> 3. Has appllcant performing removal In the City of Tracy obtained a 'Grading and Excavation Permit? <br /> N/AJ��( YES I ] NO [ I If YES, Permit # L)Ari r_!J <br /> 4. Has the contractor obtained approval from the local rue department to perform tank cutting? NA YES( ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tanks) and or piping? (If yes, please explain) YES ( ] NO <br /> /1 Slit ZJspccTinnj RcS�/ Tr/1 LN Nr 040 SOUS StGivs nL 4llAbE o� <br /> .CJEI. f)tL n)bR WERE Art ) o6tLT00S 0Je)4S PkeSE1UT <br /> , <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> NamePFiTR,)LEUM REC,,KL '�u6r LDeP02ATibAkaulerRcestration # fP/} C4Oo33/C677.`� <br /> Address_1 3 1 N . h11AJ t/ 33 City P47ER-SOA/ zip gS363 <br /> Phone # ( ADr7 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YESY NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name Wkti`Nr eA)V1 0/i)/c'1GN7AL SE,ed.CeeS, 2'iuG <br /> Address hhl �Z — City TRAGI/ Zip 4x376 <br /> Phone No.( -oc tS33- 07s-j <br /> C. Describe method to he used for decontamination: <br /> YACUUM WATER cdNTilryed rA) TiA)k tiJjo TAn1KE,e TRVck krvse <br /> T<1n))( ZNT[`2I0✓< VJITH WgT'eK fln),n VrIGd[)M /1LN5ATC <br /> d. Describe bow rinsate material will be stored onsite prior to manifesting offsite <br /> �cn/SArt [,t)ZLL NOT i3e 5ntce ,o O/J SLr=. UAGvuM TR✓�l// <br /> W26L /ZEMDJC RxV-5,4re 12iNSire Cc 6t i 124E-0 <br /> e. Rlnsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name �gAI)f /-]._`. f7h M �6) ildodC Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />