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(a) Is there a PHS-CIID contractor's questionnaire on file or enclosed? YES [ ] NO [� <br /> (b) Is the current certificate of worker's compensation insurance on tile? YES [,r NO [ ] <br /> (c) Does the contractor possess a 'Hazardous Substance Removal Certification'? YES [v]/� NO ( I <br /> 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES ["j NO [ ] <br /> 3. Has appy cant performing removal in the City of"Tracy obtained a 'Grading and .Excavation Permit'? <br /> N/A [IT YES [ ] NO [ ] If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[L1141S[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or iping? (If yes, please explain) YES NO ( ] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: rXAj/:'S 1't d Mb /N <br /> Name /A- Hauler Registration # <br /> Address City Zip <br /> Phone # ( ) <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) an I d'p' iping_lbe decontaminated prior to removal? YES ( J—NO ( ] <br /> b. Identify contractor performing decontamination: <br /> 11 <br /> Name—, :qrc All—: C,.. �:. C-,�.i r,;_ �......�1—T7,,.6 <br /> Address`L<'C �r, � iw/ i ,i'_ City 'Tc ,� c_�n.0 Zip <br /> Phone No.( <br /> C. Describe method tobeused for decontamination: <br /> 4Cih �:AI-G /S A16T <br /> d. Describe.how rinsate material will be stored onsite Prior to manifesting offsite: <br /> =�A,/We L_ ( c° K.,31-At-e 1 s tilc r lu�cGti: lx':. / <br /> (�+'e2�ii r..yits Aln r /JGTt,rG 1,2Are <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Namur jV1 X,e.) ,.tauler R <br /> �`/ egastration # �> <br /> Address />.Ssf Svc, City ' 7T;2-`r1lt� Zip Cr,, <br /> Phone No. ( 9'f'Y )►! II C <br /> Permitted Disposal Site �LR'n �f>�J�( CESS TV // �i�%.e� c 5,e;;C <br /> Page 4 <br />