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1. (a) Is there a PHS•EHD contractor's questionnaire on rile or enclosed? YES [ J NO [ ] <br /> (S-c Cc0 car 1ctFcr Z}em 1) <br /> (b) Is the current certificate of worker's compensation Insurance on rile? YES [ ] NO [ ] <br /> (Sea (aver Ict{er ';}e v.. 1) <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification? YES [ 7 NO [ ] <br /> ( Sc( Cover le t}.r T"tvm i) <br /> 2. Has a 'Site HeattJh & Safety Plan' for this Job site been submitted? YES [ ] NO <br /> (c-ee Co Vel' \e F1-er 4) <br /> 3. Has applicant performing removal In the City of Tracy obtained a 'Grading and E=svation Permlt`7 <br /> N/A)�( YES [ J NO [ J If YES, Permit # ,L <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NApC) YES[ J NO[[[[[J <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If}'es, please explaln)/ ,YES [ ] NO p� <br /> 6. If tank residual exists, Identify transporting harsrdous waste hauler. / ' <br /> Name See ever �el}er 3.}e�,,,1 1 HaulerRegislration # <br /> Address City Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedmrs <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES YJ NO [ J <br /> b. Identify contractor performing decontamination: <br /> Name Sec (over let4er �4ev� 1 <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> -11Vde(001.(4WI R 1 1r " Met�cd u111 10 ycm QPi9yWeel 4cd will fu- <br /> �nduc d in areore(amrr C')/M rrGua rt /(rot c nZ: aka rZ414V r a d&'r1C41 T <br /> d. Describe how rinsate material elll be stored onsite prior to manifesting offsite: <br /> Fjo �uucsv.YyiNSab 40(1/ 6r Slo>cd cwsr7i t4 Vyoec>' c 1i'acfOr rH acro.-daaa 'r AL <br /> irGuoa7 la-a� sfo7- o�d FtdPnz! r^rrt 0 droviS' <br /> z <br /> e. Rlnsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name �P1em I Bauder Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> Page 4 <br />