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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES NO [ ] <br />(b) Is the current certificate of worker's compensation Insurance on file? YES [ [ NO [ J <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? NO [ J <br />(d) Has everyone on site, including cranelbackhoe operator, been certified n� <br />to work on hazardous waste site In accordance with CCR Title 8? NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES�M NO [ ] <br />3. Has `applicant performing removal in the City of Tracy obtained a "Grading and Rxcavatton Permit"? <br />N/A p� YES I ] NO[] If YES, Permit # <br />4. Has "`the contractor obtained approval from the local fire department to perform tank cutting? N*YESI ] 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, Identifytransporting hazardous waste hauler. <br />Name[(11/.L(.1-Z/n 2801_ �%�U � SCS Haular Registration iF �JrS j <br />Address , ,-�j .�/�r� L L�� City / / Zip <br />Phone y (.� �0 ) 12 9 <br />Decontamination Procedures: <br />a. will tank(s) and piping be decontaminated prior to removal? YES O NO[] <br />b. Identify contractor performing decontamination: <br />Name ! 1�-h <br />Address <br />Phone <br />e Describe method to he ed for decontamination: <br />City <br />d. Describe how rinsatem tenial will be stored onsite prior to manifesting offsite: <br />/)7' <br />) 7/ <br />E <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facluty. <br />Hauler Name n �%� _ Hauler Registration s1_ <br />Address City Zip <br />Phone No. L_ <br />Permitted Disposal Site <br />EH 23 046 (Revised 08113/99) Page 4 <br />