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1. (a) Is there aPHS-lam contractor s questionnaire on file or enclosed? YFS] NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES NO [ j <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification".' YES pQ NO [ J <br />2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES [V' NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Foca tion Permit? <br />N/A [ ] YES [ ] NO [ ] H YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[4 YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO V <br />6. H tank residual exists, Identify transporting hazardous waste hauler. SyMrLy <br />Hauler Regist Gout# c c zs 5�2 3 5 <br />Address84-60 AM(' -U il sT-reU — City co"Kb Zip c{ -W?j <br />Phone # (SIO ) (0 3 3 -- © 3 <br />a. Will tank(s) and piping be decontaminated prior to removal? YES L� NO [ ] <br />b. Identify contractor performing decontamination: <br />Name C)�2osL\) d/1—o &-in0to SIJG- <br />Address D l C� 1�1-i1 ] (3U i � L'Z TT City rl /�il� Zip % 4&, L / <br />Phone No.( SI D ) b <br />C. Describe method to be used for decontamination: <br />Efe i f-cl-' Ri KSI- =4- Y)" �L-CC <br />d. Describe how rinsate material will be stored onsite prior tomanifesting oQsite: <br />M n�il�t �TzTD ox> Stjzr TO A4j ✓�-t-F-S,64, <br />e. Rinsate Hauler and <br />,. p�ernritted Treatment, Storage & Disposal Facility: smm— f4& -r. rt.� a [ 027 <br />C ti513y 4- CSU E TTA\) cl Hauler Registration <br />� ¢ <br />Hauler Name # <br />Address Fq--��% AMLLt4A ' TOLL -T-- City 04 LAfJi�) Zip -I5O2-J <br />Phone No. (Sl 0C-) � <br />) !��-> <br />Permitted Disposal Site Rom I C <br />Page 4 <br />