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V <br />I. (a) Is there u PIIS-EIID contractor's questionnaire on file or enclosed? yE S NO <br />(b) Is the current certificate of worker's compensatlon Insurance on file? [v]/NO [ <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification -1 YES M-' NO [ ] <br />2. IIas a 'Site Health & Safety Ilan' for this Job site been submitted? YES [VK NO [ J <br />3. ?las a`p� cunt performing removal in the City of Tracy obtained u 'Grading and Excavation Permit"'? <br />N/A Cl YES [ I NO [ ] If YES, Permit # <br />4. <br />5. <br />G. <br />Has the contractor obtained approval from the kcal fire department to perforin tank cutting? NA[WY ," ] O( J <br />Is there kno ledge or evidence of leakagef m the tank(s) and/or piping? (If yes, please explain) YE.S NO <br />� <br />li - 93•yzz, - � �6s X93-os7 G.oa•-� � -�� <br />If tank residual exists, Identify transporting hazardous waste hauler: <br />Na C --M vfjz �:> � Y� � t - ?Hauler Registration #O� <br />` 1 <br />+ Address / > <br />City <br />Cl f t irSL►� y t -E= Zip <br />Y o <br />rPhone # <br />7. Decontamination Procedures: <br />It. Will tank(s) and piping be decontaminated prior to removal? YES [►1 NO ( ] <br />b. Identify contractor performing decontamination: <br />Name _:5� <br />Address-� ��. l�j+�L City c�t.�,� ( Zip <br />Phone No.(l '' `'` <br />c. Descri method to be used for decontamination: <br />Describe how rinsate ma <br />or to manifesting offslle: <br />C. Itinsate Iiauler and permitted 'Treatment, Storage & Disposal Facility: /. <br />Iuuler Name �,/ [� 1�/,�� „f'�• Hauler Registration # ' e� <br />Address /YGv �,.7 > j r'f�/-� City -u�c 7,3pJ <br />Phone No. <br />Permitted Disposal Site <br />Page 4 <br />