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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YE ] 1 O INKJ <br /> (b) Is the current certificate of worker's compensation insurance on file? YES O <br /> (c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES 1 •`O [ <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 NO [ ] <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [1•j' NO [ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br /> N/A"�J YES [ ] NO [ ] If YES, Permit 9 <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAA] YES( ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES ( ] NO Mf <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: <br /> Name2���}(� [/V Vitt 1,j lA &TH Hauler Registration # <br /> Address X qT ?c City '/�— Zip - <br /> Phone # O '797 0 fl <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES f�Q NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address / [ � �/1)/ f�Ll City -1 ��J �1�JZip �J <br /> Phone No.(�) <br /> C. Describe method to be use <br /> for deco Lamination: <br /> L4 <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> IF AA)LAAM­ <br /> e. Rinsate Hauler and/ "permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name_ l f'j /s�l1f/}TE� /'>�/'iiiA?6AI6(�"I/. Hanley Registration # <br /> Address /), & City —Zip 9,463 -7 aQ <br /> Phone No. ( 7 ) 797 F,5// <br /> Permitted Disposal Site �YJSp -,�>/YCL'D�iVp�jlf]" <br /> 5/20 <br /> EH 23 046 (Revised 9/11/96) Page 4 <br />