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f (a) Is there a PHS-EHD contractor's and subcontraetor's questionnaire on file or enclosed? YESK NO[j <br /> (b) is the current certificate of worker's compensation insurance on file? YESX NO[j <br /> (c) Does the contractor possess a"Hazardous Substance Removal Certification"? YES k NO[j <br /> (d) Has everyone on site,Including cranelbackhoe operator,been certified <br /> to work on hazardous waste site In accordance with CCR Title 87 YES,Qy NO[j <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 /> YES[] NO[] If YES, Permit M ���/// <br /> 4 Has the contractor obtained approval from the local fire department to perform tank cutting?Nq�YES[[NO[[ <br /> 5. Is there knowledge or evidence of leakage from the tank(s)andlor piping? (If yes,please explain) ,YES[j NW1(_ <br /> 6. If tank residual exists, r. <br /> tIdentify transporting hazardous waste hauler <br /> Name ��//yfLnl?l614ei V�lG�c l Hauler Registration M14� <br /> Address �� `,OX 3 D City C/ Zip C? <br /> Phoney( 2� 9 ) S�6 7 — ^76 7 s �- rte—�73 Z efW S <br /> 7. Decontamination Procedures: - <br /> a Will tank(s)and piping be decontaminated prior to removal? T&3 NO(] <br /> b. Identify contractor performing decontamination: {' <br /> Name � `©//L /,Vc. <br /> Address 3 S 7 NJ- I��G/e�,��/ Qty ap <br /> Phone Not 9 L(-6 2- 'Z S� <br /> C. Describe method to be used tar decon on <br /> i,z ze /n/s E- c,/, Ta/ 19s Til 9Fv/ <br /> d. Describe how Ansate material will be stored onsite prior to manifesting offsite: <br /> e. Rlnsate Hauler and permitted Treatment,Stowage&Disposal Facility: <br /> Hauler Name 4L;,(I t�4 / ]//�Lf.L r/� Hauler Registration! 3 7 <br /> Address l BCJX .3 D City zip C/f 3/ <br /> Phone No.( Z 09 ) 5-i; 7 76`E5 <br /> Permitted Disposal Slte Ii iIZA 119s) eT � %��/� K 5-3 o L - <br /> EH 23 496 (Revised tO IMS) Pap q <br /> 7 �z6� <br />