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1. (a) Is there a PHS -SHB contractor's and subcontractor's questionnaire on file or enclosed? YES kJ NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YEW NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES <br />,Q NO [ ] <br />(d) Has everyone on site, including cre nelbackhoe operator, been certified <br />to work on hazardous waste site In accordance with CCR Title 8? YES Pq NO [ ] <br />2. Has a "Site Health & Safety Pim" for this Job site been submitted? YES`N NO[] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIAX YES NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA)q YES[ ] NO[ 1 <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NQx" <br />6. If tank residual exists, Identify/f)/1 /T f'�II transporting hazardous waste hauler. µ fA <br />Name Lw(,- 7")/) "I / /Hauler Registration # <br />Address I.S%5 tiler 61 Cltyw, /I%>e 7dP. P9� <br />Phone # ( 9/&) ) 3-)x"5--) <br />Decontamination Procedures: CTR tit 14 (3 E L I E V C D %-9 E 9M f 7-i/ —Wo R ES I b LIAL) <br />a. Will tanks) and piping be decontaminated prior to removal? YESP( NO[ ] <br />b. Identify contractor performing decontamination: <br />Name <br />Addresi o. / G • .1/11 S}.���city Zip t53 V. <br />Phone No �2,233 -�2/�7;G J2 <br />c. Describe method to be used for decontamination: <br />d. DeRxibe bow rhtsate materiel will be stored onsite prior to <br />e. Rlnsate Hauler and permitted Treatment, Storage <br />^& Disposal Facility: <br />Hauler Name�G,W�j�li i �D✓I /71 e,U I�1� Hauler Registration # <br />Andreas / � S �,'i)iY C1cdaCne,n� 21p �6�1 <br />Phone No. <br />Permitted <br />HH 23 046 (Revised 10119198) Page 4 <br />