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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br /> YESY3 NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES NO [ ) <br /> (c) Does the contractor possess a 'Haardmrs SubetaaR Ramal Certl5cation.., I,ES,<] NO [ ] <br /> 2. Has a 'Site Health & Safety Plan" for this job site been submitted? ,�{ <br /> IBS r� NO [ ] <br /> 3. Has ap licant performing removal In the City of Tracy obtained a 'Grading and Excavati Permit" <br /> N/A YES [ ] NO [ ] H YES, Permlt # / d-r0 \ / <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NXYES[ l NO[ <br /> kj <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain))___ ��`YES [ ] N01� <br /> 6. If tank residual exists, identify transporting hazardous waste hauler- <br /> Name <br /> aulerName AEidLF �N� R� VGLLiJG �De (ai �/fJC,94 <br /> t �Hanler <br /> Registration # Q02&6 7 8 <br /> Address 13.33/ Al . }flU )/ -t CIty /,4MF,2. Al Zip <br /> Phone # fj']L/— <br /> 7\ Decontamination Procedures: , J <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [ NO [ 1 <br /> b. Identify contractor performing decontamination: <br /> Name_6112LblaT F/Nc)XtQ0Aj MENTAL ,�5,8t1Z c < <br /> Address s <br /> City Zip <br /> Phone No.( ) Z <br /> C. Describe method to be used for decontamination: <br /> VL-VU'44REs4004C LLQV RVH ANjr FLUS// TAA/" T ATOP <br /> /+nJ ✓)4GuvM kr <br /> ,4)S.4 LJTG TAn/l�f� kuc <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> LfJSk72-- bL U- /JOT <br /> fnI.LCC )—A!AF a7 ECYC4Y-Al6 GAC,t4IT/ 0.4 /tit/Grialf,G <br /> e. Rlnsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name_ Srl�vJr fJS LTr� 6 �9.r3dllf hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />