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1. (a) Is there a PHS-FM contractor's questionnaire on file or enclosed? YES K NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file'• YES 14011 <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification`? YES NO [ 1 <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted'. YES NO [ I <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit' <br /> N/A [ ] YES [ ] NO [ 1 If YES, Permit # N//�G <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAVYES[ ] N0[ 1 <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain)/YES [ ] NO [�Q <br /> 6. If tank residual enlists, identify transporting hazardous waste hauler. <br /> Name /rGL(E� ��/ZOL[=Uyj Hauler Registration # ( S$ <br /> Address /'O, 1�;o,t /9'3 City 4je"5E570 zip 9S3sz <br /> Phone N ( ZOq ) S�6 g _e <br /> 7. Decontamination Procedures: <br /> a. Will tanks) and piping be decontaminated prior to removal? YES NO [ I <br /> b. Identify contractor performing decontamination: <br /> Name 54' tP60 <br /> Address /2/ 7� �f� 5?Y2ErET City /�D4ES7'o zip 9S3S/ <br /> Phone No.( Z09 ) 5z� 9653 <br /> C. Describe method to be used for decontamination: <br /> THE i4i7/C rV /101iD6 &//LL 136 721,01 ` /90'a5l' 6 s] Iwt) <br /> UD /br9 THE e2A NSE =44U4E 77.1,57 CIS OL <br /> F3 /DOL6 Pf49S -E OETISP6Eyf T4E o.)O .y9C iQlVSE3 461C <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> ,Q/vSA7E X01. 71 eble LU/CL &E .4PAEO /'v &7 I?t $ Jr 6RLGOiIi <br /> OoumS 4//71` AF/,to,'��E GaheG5 <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name <br /> / ET/Z0664 1 Hauler Registration # 11S8 <br /> Address P,O get, /93 City Zip 5952 <br /> Phone No. ( 2og ) 5n 4�SOO Q <br /> Permitted Disposal Site �E�/N�R�j S�CdIGES ��'rTT6PSDrv, G�i� <br /> Page 4 <br />