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1. (a) Is there a PSS-END contractor's questionnaire on file or enclosed? YES ['f No [ ] <br /> ' (b) Is the current certificate of worker's compensation Insurance on file? YES [.1' NO [ ] <br /> (e) Does the contractor possess a 'Hmzardow Substance Removal Certification`? YES f.' NO [ ] <br /> ' 2. Has a 'Site Health do Safety Plan'for this Job site been submitted? YES [-f NO [ ] <br /> 3. Has applicant performing removal In the City of Tracy obtained it 'Grading and lucavation Permit'? <br /> NIA [ YES [ ] NO f ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[IYESf I NO[ I <br /> ' S. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (i[yes, please explain) YES [ I NO Fir <br /> 1 <br /> 6. If tank residual exists, identify transporting hazRrdous waste hauler. <br /> ' Name fJ J r - (A L IA f ST- Hauler Registration # <br /> Address ' t�' D� i/L7 --- City � _ OJ Zip_ <br /> ' Phone # 4'~ <br /> ' 7. Decontiunination Ptx=dures: <br /> IL Will tank(s) and piping be decontaminated prior to removal? YTS R-- NO [ I <br /> b. Identify contractor performing decontamination: <br /> Name A fJ CO <br /> 1 Address �_ �; S' A-d = City '" r .Jy Zip <br /> Phone No.( <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offs[te: <br /> l/At <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name c % -+ - ' . _ Hauler Regfistration # <br /> .- <br /> Address 3-3�j �`.� f;14�, �-, 2- .� City J Zip <br /> i <br /> Phone No. ( _ ) zl £' <br /> ' Permitted Disposal Site JJ - I +" +- 's- <br /> 1 Page 4 <br />