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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? YES [ ] NO [ <br /> (b) Is the current certificate of worker's compensation insurance on file? YES I ] NO [ l <br /> (c) Does the contractor possess a Mazardous Substance Remaral Cstificatioam? YES NO [ <br /> 2. Has a 'Site Health&Safety Plan'for this job site been submitted? YES J/�' NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and ovation Permit'? <br /> NIA [ ]' YES [ ] NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to performs tank cutting?>KYES[ ) NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] N <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name Hauler Registration# <br /> Address <br /> .2 Cl�► �� Sr'�r city�r m bane i o'o zip 4/1)7 <br /> Phone # <br /> 7. Decontamination Procedurm <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ j <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> C. D cribe method to be used for decontamination: <br /> C - <br /> d. De be how rinsate materia] will be stored onsite pri r to manifesting offsite: <br /> >Uc C - :-, e7i ] %!7 ✓ Cvi.1 i I, urt< 27 -;- o i2C1 C pal S I <br /> e. Rinsate Hauler and p mw1itiW Treatment, Storage & Disposal Facility: <br /> Hauler Name f %J PL'i' CQ� Hauler Registration # <br /> Address VX4 111 A e7 4`Il City Zip <br /> Phone No. ( <br /> Permitted Disposal Site <br /> Page 4 <br />