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1. (a) Is there a PHS-EED conn -actor's questionnaire on file or enclosed? MSV< NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES Iy NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification" YES NO [ ] <br />Z Has a 'Site Health & Safety Plan' for this job site been submitted? YES NO <br />3. Has aQ rcant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit' <br />N/AYES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAKYFS[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YFS�y NO [I <br />is <br />6. If tank residual exists, identifyunsporting hazardous waste hauler- <br />Name <br />auler <br />Name Hasler Registration # <br />Address City Zip <br />Phone # ( ) <br />7. Decontamination Procodnr= <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO <br />b. Identify contractor performing decontamination: <br />C. <br />d. <br />e. <br />Name U) r � <br />Address BIZ J l� h(v�V�L �^ \ Lr,J?S/City r zip q <br />Phone No.(� �� ) Ly <br />used for <br />S <br />Desc'ibq how rinsate material will be stored onsite prior to manifesting offsite: <br />Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />�,iy„ryr„�, (�,;�, �'{' Hanler Registration # ",o set <br />Hauler Name �1r <br />Address 7'`��� b City Zip �S C <br />Phone No. LTJ= <br />Permitted Disposal <br />Page 4 <br />