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1. (a) Is there a PAS-EHD contractor's questionnaire on rile or enclosed? <br />yEN No [ <br />(b) Is the current certificate of worker's compensation insurance on rile? Y'S <br />NO [ � <br />ous Substance Removal cation'? <br />Y6DI No � <br />(c) Does the contractor possess a [ NO <br />2. Has a 'Site Health & Safet, Plan' for this job site been submitted? <br />obtained a 'G and Excavation Permit'! <br />3, Has ap licant performing removalN,n the City � Vic}' Permit # <br />NIA � [ <br />s[] NO[i <br />4, Has the contractor obtained approval from the local fire department to perform tank cutting. NA ms <br />vidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ l N® <br />;, Is theft knowledge or e <br />transporting hazardous waste hauler. i7A <br />6. If tank residual exists, identify transp g { Registration <br /># <br />Hauler Regi <br />Name <br />City Zip <br />Address <br />Phone # <br />Decontamination �: <br />�j � NO <br />a, Will tank(s) and piping be decontaminated prior to removal? <br />b. Identify contractor performing decontamination: <br />Name <br />� � a� —' zip <br />Address 2 � "'> city O <br />Phone No. '� ' C 2 <br />C. Describe method to be used for decontamination: t'- rJ 4S <br />--tea V. ZA2 <br />sate material will be stored onsite prior to manifesting offsite: <br />d. Describe how rin <br />e, Rinsate Hauler and pmmitted Treatment, Storage & Disposal Facility: <br />Hauler Registration d 1 <br />Hauler Name <br />Zip <br />Address S <br />City® 1>0 0 <br />Phone No. 6 ti ® <br />Permitted Disposal Site <br />Page 4 <br />