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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YESS-K NO ( ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES.X NO [ ] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES-N NO [ ] <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YEW NO [ ] <br /> ?. Has a "Site Health & Safety Plan" for this job site been submitted? YES I" NO ( ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/ASV] YES ( ] NO [ ] If YES, Permit # <br /> 4. Has /the contractor obtained approval from the local fire department to perform tank cutting? NAK YES[ ] NO( ] <br /> 5. Is there knowledge or eviden a of leakage from the tank(s) and/or piping? (If yes, please explain) YES D(J NO ( ] <br /> So.I /Mik) 'IOCItra$Pr <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name j (VLQ�(� 0.� �}/yy'��^-�c-�'a� Hauler Registration # <br /> Address �� -1 V City_ Zipqi:� 31,� <br /> Phone # ( 300 3a �(0 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES,K NO <br /> b. Identify contractor performing decontamination: <br /> Name �MLY( [(l o Ia V QQ,� <br /> Address �,0 . V(,r x �(-1 V City L cl V1 i Zip 1,:�- I i <br /> Phone No.(_ �6b ) '] 2)a - q(P y5 <br /> C. Describe method to be used for de ontamigation: <br /> d. Describe how dpcatn marnr ai will he %tared onsite prior, to manifesting offsite: <br /> Jv\s o x�� � VwYA kA init e4 foa-1 V'0: �re-✓ <br /> e. Rinsate Hauler and permitted Treatment, (S�toolrage� & Disposal Facility: -7 <br /> Hauler Name / ]muf I/LG(`yx VQ�()({(� Hauler Registration #.- -/7Nj q <br /> Address City _Zip J/ <br /> Phone No. <br /> Permitted Disposal Site <br /> �/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />