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12/09/2004 11 : 41 FAX 2099333199 1A 003/005 <br /> Dec , 3 . 2004 4: 30PM • • NO -COBB P . 5 <br /> (b) is the current certifiCate of worker's compensation insurance on file? YFSi\) NO[] <br /> (c) Dves the contractor possess a"Hazardous Substance Removal Certification"? YESNNO[] <br /> (d) Hes everyone an cite,including crane/backhoe oparatvr,been certified to work on <br /> (e) hazardous tvastr site in accordance with CCR Title 8? YES[] No[] <br /> 2. ilea a'Site Health&safety.Plm"for thio job site been submitted? Y&-,O- No[] <br /> 3, Hu applicant performing removal in the City of Tracy obtained a'Grading and E=avaticm Permit"? <br /> N/¢ 1 YE+[] No I] [f Yes, Permit H <br /> 4. Has the contractor obtained approval&rant the local fke department to perform tank cutting?NA[]Y NO[] <br /> 5. Is there knowledge or evidence of leakage from the taWe)and/or piping? (if Yes,please explain)YO;[] NO <br /> 6. If tank residual§Afft,identify transporting hazardous waste hauler. <br /> NameEVES2C�REEtJ E1Jy1R�1�11y1Fti1ml Hauler Registrationi_64Q /0241132X02 <br /> Addnw_ 12��lE: city N wA K zip 9`15100 <br /> Phone 0( <br /> 7. Decontamination Procedures: <br /> a. Will tanks)and piping by decontaminated prior to removal? YESA No I I <br /> b. Identify contractor performing decontandnativn <br /> i <br /> Name ktNJS C„iVt"Lo"J AL" t. Mo/tcv l" C <br /> Addtees ZR X 36" k 9s—.12 <br /> City-� cc c^N �p <br /> Phone No. <br /> G. Deecdbe mekitod to be us for decors ton <br /> d. Describ?eJ,WVrinse materia]will be stared onsite prior to manifesting <br /> OA <br /> Sr l4KJ � 2A✓6_ -Nr�4'4 <br /> a. Rinsate Hauler and permitted Treatavmt,Storage&Disposal pacility; <br /> Hauler Name_�V L_'fL Si!2 6 •✓ (-�"iv v/ I2 v Hatiler Regiskalion M�'p L�13 a�z <br /> Addn'9s Ls� eo sol,i /A !"y1y 6— city, lt1 F>WL�((L �: Zl <br /> 7 p <br /> Phone No.( ._1 l` ����— / / '� rJ V <br /> Permitted Disposal Site <br /> EH 23 DM (Revised 101103) Page 4 <br />