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0 0 <br /> • 1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES NO ( ] <br /> (b) Is the current certificate of worker's compensation insurance on file? YES [ J NO [�c] <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES ( ] NO [ J <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 NO [ ] <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES bt] NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A)J YES [ ] NO [ ) If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAD4 YES[ ] NO( ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO <br /> 6. If tank residual exists, identify transporting hazardous 11waste hauler: <br /> NameAMQU('1 -,� Uo. O. Er4v vt,1acR Hauler Registration # ac]Z51 <br /> Address Z`13a Cne4r Y, ) City 1 0iLLk Zip c`lS3$0 <br /> Phone # <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 <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Hauler Registration # <br /> Address City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />