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0 <br />1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES(] NO[] <br />(b) Is the current certificate of worker's compensation insurance on file? YES [.]ANO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [�0 [ ] <br />(d) Has everyone on site, Including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES [,]-[ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES (,] NO ( ] <br />3. Has applicant performing removal In the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA (] YES [ ] NO ( ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA( ] YES( ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [vl�' <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name j' ( _ Hauler Registration # <br />Address 1/� L1 Lt ua. qty i( zip+4a-) <br />Phone #(,-' 5rC, <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YESW NO [ ] <br />b. Identify contractor performing decontamination: <br />Name (—I('—T— <br />Address D-�5 15 � /� ►b� rUC1City/ t( Zip <br />Phone No4 _) 9S ] 31 � <br />C. Describe method to be used for decontamination: <br />-T-/V 11 V11 , G 9 1'.1 1"; <br />d. Describe how rinsate material will be stored onsite prior to manife ting offsite: <br />t.�-C-1JLa. <br />10� <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name � C11 — p I Hauler Registration # q� 5 c3 3 <br />Address 3�5 62Q/t/t 630A City?\fct'I/1"VM Zip I�tC�o <br />Phone No.('�10 {{ p <br />Permitted Disposal Site � /1 VUC1. �iG]+�01 GI CA - <br />EH 23 046 (Revised 10119198) Page 4 <br />L. <br />