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t . <br /> 1. (a) Is there a PIIS-EIID contractor's questionnaire on file or enclosed? YES NO [ ] <br /> (b) Is the current certificate or worker's compensation insurance on file? YES NO [ J <br /> (c) Does the contractor possess a 'hazardous Substance Removal Certification'? YES K NO [ ] <br /> 2. Has a "Site Health & Safety Plan' for this job site been submitted? YFS NO > <br /> 3. IIas applicant performing removal in the City or Tracy obtained a 'Grading and Excavation Permit"? <br /> N/A [ ] YES [ ] NO [ ] If YES, Permit # <br /> 4. IIas the contractor obtained approval from the local fire department to perform tank cutting? NA YES[ J NO[ ] <br /> 5. Is there know edge or evide ��f leakage from t� tank(s) �qd/ r pipi S JK? (If yes, please explain) YENO [ ] <br /> fttLie �t t2 wi a�t'f'" <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> idu <br /> Name ( 6J &1 �y 1 C Hauler Registration # <br /> Address �Zr7d C W L t✓�J11tACity ) Zip 14b� <br /> Phone # ( �I'S3 - 4 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br /> b. Identify contractor ppe/rforming decontamination: / <br /> Name '~ l [ 1 113 J i(Loti M&)OT4 L C..,E 5 <br /> Address ' ZU LH 1,K A s!ti) S'i City f� "� Zip V 07 <br /> Phone No. <br /> C. Describe method to be used for deco tamination: <br /> ' L C 1 0 SV a A <br /> d. De ribe h w rinsate material wil be sto onsite gqrior manifesting offsite: <br /> OV% 1 G , "1'� SIAUtiut4 <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name �+J F Se 0_%Jf(_C, Hauler Registmtion # <br /> Address ��W 1 0-5 q t'�0+,1 City Zip <br /> Phone No. ( ) <br /> Permitted Disposal Site �/U L11 1"�tIJ i e-L <br /> Page 4 <br />