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1. (a) Is there a PIIS-EIiD contractor's questlonnnlre on rite or enclosed? YTS ki NO [ ] <br />2 0 1995 <br />(b) Is the current certificatt of worker's compensation Insurance on file? YES Ed NO [ ] <br />JVIRONMENTAL HEALTIi / <br />(c) Does the contractor pons ss a 'Hazardous Substance Removal CbFMAB RVICES YES RJ NO [ ] <br />2. Has a 'Site Health & Safety Pian' for this Job site been submitted? YES [,�NO [] <br />3. Has applicant performing removal In the City of Tracy obtained a 'Grading and FSc®vatlon Permlt'? <br />N/A [-jam YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local tire department to perform tank cutting? NAt- YES[ ] NO[ ] <br />S. Is there knowledge or evidence or leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [/ <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name F gA05. l IEZ9t`!��t�T�l� _ Hauler Registration i. 05 19) <br />Address 41:-1S �)DUTIt jZIVEIz WVA'T7 City w, r7( hnt7Zlp <br />Phone # ( ({ I (0 1 EL <br />7. Decontamination Proeedm-m \ <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [)] NO i , <br />b. Identify contractor performing decontamination: <br />Name IdL[t�E�lsrl�on4'.f� CClkTypLO�( <br />Address 1420c;c' F',dG4er—o fSLVD City Zip 9q2t;,zi <br />Phone No.( `z'10 ) 3i2 -41190 <br />C. Describe method to be used for decontamination: <br />T9 -/Pry izintaWC, iti-r+ MPrtlrm d� us`C a���ntrdutrua-(rtxJ <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />Tst.L5tiTMr wA nsuA- . WILk. Px!5 16Ac-uuwr 7 lung A. -r,W Utz T7_ttc4z— <br />e Rinsate Hauler and permitted Treatment, Storage & Disposal racility: <br />Hauler Name ISD, >�_ #� , Hauler Registration (f <br />Address City_ Zlp <br />Phone No. ( ) <br />Permitted Disposal Site <br />Page 4 <br />