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1. <br />2. <br />3. <br />4. <br />5. <br />7 <br />(a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed?� YES [q NO I J <br />(b) Is the current certificate of worker's compensation insurance on rile? YES IkI NO [ ] <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification'? YES [t]' NO [ J <br />Has a 'Site Health & Safety Plan' for this job site been submitted? YES 64' NO [ ] <br />Has apf�licant performing removal In the City of Tracy obtained a 'Grading and Excavation Permit? <br />N/A t ] YES [ ] NO [ I If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAp.j YES[ ] NO[[ J <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [If <br />If tank residual exists, identify transporting hazardous waste hauler. <br />Namei_ ' _ - (. S r v LQ e cc <br />Hauler Registration <br />Address City Gl . F v zip �� �(.'� <br />Phone # <br />Decontamination Procedures <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [(] NO [ ] <br />b. <br />C. <br />Identify contractor performing decontamination: <br />Name Ya ` r n ST V - r n(i pp� qq <br />Address f: -- y \,A City Z�LiiCJoS( �l C I(Zip <br />Phone No.(T_) <br />Describe method to be used for decontamination:, <br />d. Describe how rinsate material will be stored onsite prior to <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal facility: <br />IIauler Name �1 V— � L Hauler Registration # <br />Address 33-2� City o Zip <br />Phone No. <br />Permitted Disposal Site <br />Page 4 <br />