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i <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 I ] NO {� <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ [ <br /> (d) Has everyone on site, including cranelbackhoe Operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES NO [ I <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES NO { ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> I <br /> NIA, YES [ ] . NO [ I If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department.to perform tank cutting? NA/YES[ ] NO[ j <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ I NO <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name f '�' �I�'i�.. � yt�:1: Hauler Registration # <br /> Address l 7 D �°�i city -i`�`_ Zip �. <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 Q A-QEi City CfAi Zip a <br /> Phone No.( '� } 1�4,�, <br /> C. Describe method to be used for decontamination: <br /> a <br /> d. Describe'how rinsate material will be storedonsite prior to ma 'festin offsite• i <br /> t. s r `. W► LL. . <br /> r <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler NamelWZWQ1E1 �anler Registration # <br /> Address ? i� �C'�'J city t Zip <br /> Phone No. ( ) —7 46 45 [ <br /> Permitted Disposal Site �� I �.l.r ... �t ��� L63 '13 <br /> 5120 <br /> EH 23 046. (Revised 9113196) Page 4 <br /> k <br />