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1 (a) Is therc a PHS-EHD contractor's questionnaire on file or enclosed? YES [`Q NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES 64 NO [ ] <br />(c) Does the contractor possess a Certification.YES [74 NO [ ] <br />r. Has a "Site Health & Safety P1=7 for this job site been submitted? YES [ ] NO <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit' <br />N/A [A YES [ ] NO [I If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NAN YES[ ] NO[ ] <br />t S.) Lc there knowledge or evidence of leakage from the tanks) and/or piping: (If yes, please explain) YES [ ] NO17, <br />rA <br />Name <br />rb Hauler Registration 7 a/(-07�$ <br />Address ab a �{ ` S 7 ce -7`" City SQC 2AM Zip �j SS 22 <br />Phone # (_q 1 (0 )- :' as —a (a a <br />7. <br />a. Will tank(s) and piping be decontaminated prior to removal'. YES [' NO <br />`Wi[ ] <br />b. Identify contractor performing decontamination: <br />Name <br />Address �S $ oi�% C�City dQCJ' Zip $ 22 <br />Phone No.( 1 (O ) 4 Z2 —Q-(0 19 <br />-:.,,. w ) rs. . » .. '.» » :,» ». • wry. » ♦:. .♦ » s.». ».. <br />#— <br />If _ - <br />d. Describe how rinsate material will be stored onsite prior to manlfestin <br />R / r):s Q ,`j u C <br />v <br />QGI ! ✓ <br />e Ri,nsate Hanler and permitted Treatment, Storage & Disposal Facilit): <br />01Ysite: <br />713 <br />Hauler Nam r <br />r -r i <br />1)rq er Registration # s� <br />Address 9 & oD, 4 »� I�u--� City „�Q G� Zip <br />Phone No. („� 1 4 2-2-A" 2C'i <br />Permitted Disposael C6». <br />C. -F 1 r 16r 4 Sv t.Ut CLL <br />Page 4 <br />1 (A 9s36 <br />