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1. <br />2. <br />3. <br />4. <br />5. <br />:2 <br />(a) Is there a PHS-EHD contractor's questionnaire on Isle or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on rile? <br />(c) Does the contractor possess a 'hazardous Substance Removal Certification"? <br />Has a 'Site Health & Safety Plan' for this job site been submitted? <br />YES [yj <br />NO [ ] <br />YES <br />NO[J <br />YES Pd <br />NO <br />YES K <br />NO [ ] <br />Has applicant performing removal In the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A r�`j YES [ ] NO 94 H YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA <br />"M YES(] NO[ j <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO W <br />If tank residual exists, Identify transporting hazardous waste hauler. <br />Name A /q C - Hauler Registration # 3C6 co z <br />Address /333/ Alco✓ 33 city Fb-7ezip <br />Phone # IC <br />7. Decontamination Procedures <br />a. <br />b. <br />C. <br />d. <br />e. <br />8711 tank(s) and piping be decontaminated prior to removal? YES " NO [ ] <br />Identify contractor performing decontamination: <br />Name ,�Cy/eS/'<L <br />Address 2236SFG /T'o,-d ' city La_�� F,, -en T�3G <br />zlp 9 2-G <br />Phone No. 7( 1,V ) �15!/ / 3QG7 <br />Describe method to be used for <br />Describe how�nsate material will be stored onsite prior to manifesting offsite: <br />1h [�r�/' cif 124AW2 Tib" <br />Wnsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name JJ hauler Registration # �z <br />Address /(/(J% � Nio% 3) CityIEZe'�t'7 Zip9,fj�5-? <br />Phone No. ( fi2162 <br />Permitted Disposal Site_ P. 9 -G <br />o � <br />Page 4 <br />