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1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on file or enclosed? YES NO [ j <br />(b) Is the current certificate of worker's compensation insurance on file? YES NO [ <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES NO [ } <br />(d) Has everyone on site, Including cranefbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES' NO ( [ <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES X NO ( } <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA')( YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA)(YES[ } NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? Of yes, please explain) YES NO [ ] <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name /a Hauler Registration # <br />Address City Zip <br />Phone #-- <br />Decontamination Procedures: <br />a. Will umoqo�ft piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Tame ----- <br />Address City <br />Phone No. <br />C. Describe method <br />>to be used for decontamination - <br />7 <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />YES [ ] N0'k <br />Zip <br />e- Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Names' _ — Hauler Registration #_ <br />Address City Zip <br />Phone No. <br />Permitted Disposal Site <br />EH 23 046 (Revised 08113/99) Page 4 <br />