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(a) Is there a PHS-ERD contractor's questionnaire on We or enclosed? <br />(b) Is the current certificate of workers compensation ins ? YES NO I ] <br />1 [crena on file. YES pd NO [ ] <br />(c) Does the contractor possess a s Sa68ra-M Rewoyxl Ca'tiSc cm.? <br />2. Has a 'Site Haft & S&f* Plan' YES K NO [ l <br />for this job site been submitted? <br />3. Has applitaintrfo YES NO [ l <br />N/A Pd YES [rm�8 removal <br />in the City of Tracy obtained a .0,,ding and <br />I I H YES, Permit # vaiion Permit? <br />4• Has the contractor obtained approvel from the local fire department to perform tank o cuttin <br />5. Is there knowledge or evidence of l g NAp�J I I NO[ j <br />leakage from the tanks) anor d/piping? Ping. (Utes, Please explain) YES I I NO <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name F�erbs7r C rn�err.-t <br />O t3 G Hanley Rtioa # <br />Address Z S$` <br />� X ZzSo ¢ �— <br />Phone # City ------------------ Zip 1` Sg 2Z <br />`�� ZZ-ZGzg <br />7. Demntamiaanon Procedures <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />YES pQ NO <br />b• Identi[ ] <br />fy contractor performing dem amination: <br />Name 17 er6s l- C <br />n i 7 e e r r,�-t <br />Address f 0 f3a Ir ZED¢ �SYj80 �¢ — <br />City sq—= Zip g Z Z <br />Phone No. g(=1 �Z <br />C. Describe method to be used for decontamination: <br />I <br />(/"42(e rtns,.t <br />d• Describe how rinsate material viii be sto <br />1 r o �� %",/onsite � manifesting offsite <br />e. Rinsate Hauler and pe <br />rmitted Treatmen g <br />t, Storage &Disposal Facility: <br />Hauler Name_1�er 6S 7L t^� <br />i i7kPn r n <br />Hanley Re <br />Address PO j3ox gispation # ZSS q <br />Cih.sGCrQ <br />Phone No. <br />Permitted Disposal Site R 4, n2 <br />dr CQ S / <br />Pa 7`ers c C,4 <br />Page 4 <br />