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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on rile? YES [rl NO [ ] <br />(c) Does the contractor possess a %2zudous Substance Removal CertiB®tion'? YES NO [ 7 <br />2. Has a 'Site Health & Safety Plan• for this job site been submitted? YES NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and E�t'? <br />Excavation Permi <br />N/A Y'� YES [ ] NO [I H YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAfg YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping?, (If yes, please explain) YES bof NO [ ] <br />6. H tank residual exists, identify transporting hazardous waste hauler. <br />Name N.tA Hauler Registration il� <br />Address City <br />Phone # <br />a. Will tank(s) and piping be decontaminated prior to removal? YES JbJ NO 1 <br />b. Identify contractor performing decontamination: <br />Name U,)0tMEr.)TWC SERw Yz f. ln1C- <br />Address_yLLc� CaYV�M£2ClAl ��.)#S City IRv�cyi CR Zip gSYI(o <br />Phone No.( ZOg ) 83 3 —O'l S F3 <br />C. Describe method to be used for decontamination - <br />?NSE v.wi'r4i wATFt2 Aroma SOA10 <br />d. Describe haw rinsate material will be stored onsite prior to manifesting offsite: <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name—1E m v \ Rc� Rug WEST Hauler RegLArntion # (n O 3 z 1 7 <br />Address �)-c�.gz. y' \\6,1 city yp mRscn))\A Zip `)S3(.3 <br />Phone No. ( 800 ) 8'1 `1 — `I 4 N L -I <br />Permitted Disposal SiteeZ C 31>ZT F Q 5 c N <br />Page 4 <br />