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AMMM <br /> S <br /> 1 (a) Is there a PHS-EHD contractor'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 [I NO [ ] <br /> (d) Has everyone on site, including crane/backhoe operator, been certified <br /> to work on hazardous waste site in accordance with CCR Title 8? YES [1-140 [ J <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [f—'NO [ ] <br /> 3. Has appAcant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> NIA W YES [ J NO [ J If YES, Permit # <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[4_VE_S[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YESX NO [ ] <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name <--,CA-1 � �- Fear Hauler Registration # <br /> Address 7'> � ��-�(1 ��t: � City�_i�:Hrr1.�0r/ ( Zip �``/FCOc/ <br /> Phone # D <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 �I 111 <br /> i <br /> Address City Zip <br /> Phone No.( ) <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name ( � i�`'C� N n!r Hauler Registration # 2 <br /> _ G <br /> 7 �.CC )ir (l�i� zip__ <br /> Address �� �Cti r f" i;�� City <br /> Phone No. ( / <br /> Permitted Disposal Site 17�k_ �, �� ( � <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />