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1. (a) Is there a PHS-EIID contractor's questionnaire on file or enclosed? <br /> � C ] NO <br /> (b) Is the current certificate of worker's compensation Insurance on Ne? _/ <br /> YES td N o [ ] <br /> (c) Does the contractor possess a 'Hazardous Sabgtance Rr=wyvW CeztiIIar[Ion'? YES NO [ ] <br /> 2• IIas a 'Bite Health &Bafety Plan' for this Job site been submitted? <br /> 3. IIas appal t performing removal In file City of Tracy obtained a 'C <br /> rading N/A YES [ ] NO [ ] If YES, Permit # and hccaraUon Permit'? <br /> 4. IIas the contractor obtained approval from the local fire department to perform tank cutting? NA[ <br /> ] NO[ ] <br /> 5.' Is there knowledge or evidence or leakage from the tank(s) andlor plptng? (If yes, please explain) YES [ ] NO <br /> 6. if tank residual exists, Identify transporting hazardous waste hauler. <br /> Nems .T�,C (- !1VE y F (� V t C,�S IIauler RcglstraUon # <br /> Address/-.51 "'-5/ nuc, t,/ T3 City . 7T�2 S� Zip <br /> Phone # ( yCt <br /> 7. Deaootamination Procedurm — <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES [ti�0 [ ] <br /> b. Identlry contractor performing decontaminallont <br /> Name J'TC(-k k=1'y(t <br /> Address � �X `S�/.� City Sz Zip <br /> Phone No.( ZUCr ) Ll< e -- x S 3 > <br /> C. Describe ethod to be wed for decontamination: <br /> ��� <br /> d. Despribe how rinsate material mil be a" onsite prior Ko manifesting offsite: <br /> e. Rlnsate IIauler an//d,, permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name�/�C, ��1'/AfF. •�`'7 AICs S Hamer ReClstration #_ <br /> Address/33.-3r I /y, ///U a J'- CYlt /' Zip <br /> r' <br /> 1r� p <br /> Phone No. L'qZ <br /> Permitted Disposal Site_j�/�!�- <br /> Page 4 <br />