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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES [Lt/ NO [ ] <br /> (b) Is the current certificate of worker's compensation Insurance on file? YES �r NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification? YES (4 NO ( ] <br /> 2. Has a 'Site Health & Safety Plan" for this job site been submitted? YES [,, NOL 1 <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Perndt' , <br /> N/A [ ] YES L 1 NO [ ] If YES, Permit # y;' e 2 n_ , e Cx.t-t1, t/-/n p"� <br /> �v'1. p�C12-toc�� i�v��.o��t n� GfJ17F�rrn <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAWYES( ] NO( ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES ( ] NO [4- <br /> 6. If tank residual exists, identify transporting hazardous waste hauler. <br /> Name ��a �_. p 1r�7 Hauler Registration ttCA1D60q 5, <br /> Address—<:9, <br /> Phone# <br /> 7. Deconntaailmtdon Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [ ] NO (/] <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: L <br /> d. Describe how rinsate material will be stored onsite prior m manifesting oQsltr. <br /> hr IE-� -� v� } � v� CS v� � i1 �,Ir,,cC mil <br /> e. Rlnsate Hauler and permitted Treatment, Storage & Disposal racility: <br /> Healer Name <br /> l�_ Haniea,-Regfstratdon * Ool 9. <br /> Address. S / < � <br /> 4J c�_ Clty. c ,c n ZIE p/ <br /> Phone No. LZ?l(DLJ ZL <br /> Permitted Disposal Site <br /> Page 4 <br />