Laserfiche WebLink
Is there a PHS.EHD contractor's questionnaire on enclosed? <br /> Me or encld? <br /> X NO <br /> ens [ ] <br /> (b) Is the current certificate of worker's compensation Insurance on file? evlc 101►ed YES <br /> NO [ <br /> (c) Does the contractor possess a 'Hazardous Substance Removal <br /> CertiScztion`.' er& YESNO [ ] <br /> -' Hasa 'Site Health & Safety Pte•for this job site been submitted? <br /> i e>7C.14h� YES NO [ ) <br /> 3. Has ap licant performing <br /> N/A`_ removal in the City of Tracy obtained a 'Gridi� ander Permit'? <br /> /�Q` Y [1 NO [ 1 If YES, Permit # <br /> 4• Has the contractor obtained approval from the local lire department to perform tank Cutting? <br /> NAXYES[ J NO[ <br /> S• Is there knowledge or evidence of Ieakage from the tank(s) and/or i in <br /> l>_ ��� P P g• (If yes, please explain) YES I 1 NO j <br /> 6• If tank residual eadsts, identify transporting hazardous wnsie hauler. <br /> :Mame hkl, ervi•Ge <br /> 1 Hauler Registration # <br /> Address_ , errU Y u11h'� <br /> Phone et'i. <br /> " P <br /> `�—� � � � �?'srSQA•#� cq <br /> Dnnc�11 11 Vgi <br /> '• Deconfamination Procedures: <br /> i <br /> �a jell tawixe*)aewd piping be decontaminated prior to removal? <br /> YES�l' NO t j <br /> b• Identify contractor performing decontamination: j`L <br /> Name I�C: . <br /> Address pyQ Phone tiiiak] <br /> C q((p _) , )Aga <br /> L/C. Describe method to be uled for decontamination: <br /> 1 <br /> / d• Describehaw rinsate material will be stored onsite prior to manifesting offsite: <br /> e• Rinsate HaulELand permliftaLTreatment,.Storage &.Disposal Facility: <br /> • Hauler Name 5'�r/I A Y <br /> Hauler Registration # <br /> Address <br /> city Zip <br /> Phone No. ) <br /> Permitted Disposal Site 16 {N Q <br /> page EQA �C*P 04; (p O -7 <br /> S <br />