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1. <br />2. <br />3. <br />(a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation insurance on file? <br />(c) Does the contractor possess a 'Hazardous Substance Removal Certification'? <br />Has a 'Site Health & Safety P1W for this job site been submitted? <br />YES !'] NO [ ] <br />YES [W --NO [ ] <br />YES & NO [ ] <br />YES &J"' NO [ j <br />Has applicant performing removal in the City of Tracy obtained a 'Grading and )dation Permit'? <br />N/A [4' YES [ ] NO [ ] H YES, Permit # <br />4. Has the contractor obtained approval from- the local fire department to perform tank cutting? NA [YES [ ] NO[ j <br />5. Is there knowledge or evidence of leakage Brom the tank(s) and/or piping? (If yes, please explain) YES [W-140[ ] <br />.T- Yto-5 -cis�lej -t-r-6,L- <br />7. <br />If tank residual exists, identify transporting hazardous waste hauler. <br />Name-42P........Hauler Registration # <br />Address I City <br />Phone # ( ) <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />Zip <br />YES[ ] NO 0,r <br />b. Identify contractor performing decontamination: <br />Name - .un..�nA <br />Address 10 N iJ W . 'V -e4 [ Ln City Zip 4 —Zko <br />Phone No.( 10CA ) rVoL7' k4 S %-Z2 <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 Hauler Registration # <br />Address City <br />Phone No. ( ) <br />Permitted Disposal Site <br />Page 4 <br />Zip <br />