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1. (a) Is there a PHS-EHD contracwes questionnaire on file or enclosed? YES [ NO [ ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES W NO [ ] <br /> (c) Does the contractor possess a Substance Removal CerdficRtiou'? YES Ll NO [ ] <br /> 2. Has. a 'Site Health &Safety Plan'for this job site been submitted? YES D4 NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Ezeavatim Pamir=' <br /> NIA [ I YES I I NO [] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAJK'] YES I NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO [ <br /> b. If tank residual exists, identify transporting hazardous waste hauler:. <br /> # oO 2 S- <br /> 6-:5-z3 <br /> 5 S .3 a`� <br /> Name C 1�4`�� �" � uG; <br /> Hauler <br /> Ix � ac <br /> Address City Zip <br /> _/ moi' 6 cam:r - <br /> Phone # (. -Z, <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name Cki ay *-- c u L,L + ,)") <br /> 1 tel_ _)hit--Zip 1 61> <br /> Address e f .�-C3 'J ,:! STK'�Zr City,_ . .(-Wt <br /> Phone No.( .5I C) ) .--, — 0 (,,::, <br /> C. Describe method to be used for decontamination: <br /> —! r—CL <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: Inv IL <br /> Hauler Name r6, r'\ -4' OV L Hauler R -' <br /> Address <br /> Phone No. <br /> Permitted Disposal Site <br /> Page 4 <br />