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a ' <br /> ! (a) Is there a PIIS FIID tautraclor's questionnaire on file or enclosed? YLS'N N(1 { I <br /> (b) Is Ilse current ctr1111cale of worker's compensation insurance on flit? YES NO I I <br /> (c) Hoes Ilse contractor possess ■ `lliardona Subelance Removal (.crtllieallon l YES NO I <br /> ' 2 Iles a 'Site lEcalih A Ssfcljr Mat for this job site been submlllcd7 YES'R N(1 [ I <br /> i <br /> 3 ling applicant ptrfornthtg rtutoval In the City of 1 racy obtained a '(:rstding and Encavollon VermlV7 <br /> ' NIA M YF.9 1 1 NO 1 ) If YHS, I'trmil N <br /> 4 llas the contractor obtained approval from lite local Hire department to perform tank cutihtg? NARYE9( ) NU <br /> ' S Is fltere ktlowledge or evidence of leakage from lite Ittttk(s) and/or plphegl (if res, please explahe) YES ) ) NOI( <br /> ' d If Iauk residual exists, Identify haneporling hazardous waste haulers <br /> Name Not --(,el wall 41 011 haillel •1 Ilaule: Neglslrallun CAI) 982411255 <br /> ' <br /> Address 645 Della I I l V l i flux A Zip 95116 <br /> llty + <br /> ' 1,11one d 209 3 P-MR) <br /> 7 Mcoulamluallon Proceduress <br /> M. {VIII lank(s) and plping be decoulandnaled prior to rtmovall YL4 NU O I <br /> I <br /> ' b Identify contractor petforndog deconlaminallons <br /> Nance ')it,, lljtti p(! (l( 1 , Irir_ / DIIA Rie h-PLIC L (ocesl a tit LIott <br /> ' Address 351 11 Ile(j(111,111 Ilii / 1' () llux _)51 (.lty I ()tli ,CA Zip 9524 l-(1)51 <br /> Phone No ( 209 ) 462-4'5()1 .11011411 flaz Kit, hetil er N 2667 <br /> C. Delcrlbe rtthnd o be d for dec9ontaminallonr <br /> Uu C l le al �'11S/1 111) <br /> d Describe haw rhuale malerlal will be stored ousile prior to manlfetiug offsilet <br /> )l►t� r i,��C L wl 11 ht!!f'.{IYc�Y�;tl by Jlut-A Qum, OILL111L. vel sot el�lr_.d placed jln <br /> ' thjj=- l_i.te lit be i-.Mini Lu 1 by us Lu out Val d aL BO Ellac.lc Ulaccwlul <br /> Riy,, Lodi {{ CA to aw e i L 111(.1( 111) by d tler,'l I I f i ecl ( (11 )e(A im company. EPA #CAI. l)I)()U 12(11111 <br /> e. Illensate Hauler •red pcxmllled Treatneed, Storage h Disposal Fecllliyn <br /> ' Ilaulcr Name Same as # 6 healer Registratlon <br /> Address City Zip <br /> Phone No ( -) <br /> Permitted Disposal Site Itel Wet les Ser ykes I'aLLel son, CA or Wier approved 17 1) Ry. <br /> Page 4 <br />