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F <br /> 1. (a) Is there a PHS-13111)contractor's and subcontractor's questionair on f l r enclosed? S 0[) <br /> (b) Is the current certificate of worker's compensation Insurance on file YES 0[j <br /> (c) Does the contractor possess it*Evardons Snbstuce Removal C d "? YES No[) <br /> (d) Has everyone on site,including cranelbackhoe operator,been certified <br /> to work on bazardous waste site to accordance with CCR Title 8? YES jy NO 11 <br /> 2. Has a"Site Health L Safety "for this job site been submitted? YES NO[) <br /> 3. Has Meant perfo g removal In the City of Tracy obtained a"G @ avallen t"? <br /> NIA ap YES() NO[1 If YES, Permit# <br /> 4. Has the contractor obtained approval from the local tire department to perform m ?K/YES[1 NO[1 <br /> 5_ Is there knowledge or evidence of leakage from the s)andfor piping? Of yes,please expl )YES[1 NO[) <br /> 6_ It tank residual exists,identify transporting hazardous waste hauler. <br /> Name Hauler Registration d <br /> f Ad ss city ZIP— <br /> Phone# <br /> .ipPhonep , _J <br /> T- Decontamination Procedures*. <br /> a. Will s)an piplu decontaminated prior to removal? NO[) <br /> b. Identify Contirzolm g decontamination- <br /> Name <br /> eeont ation-Name o-t U 1 n j(N <br /> # Address '(D 5 q Luca(e)e, Ave, . City 6Lu.KinZip <br /> Phone Flo{ alp I <br /> C. Describe method to be used for decontaminatlor. <br /> . Describe how Ansate material will be stored onsite prior to manifesting offsite: <br /> Shred ` . D.T. brt.Lm s rme.r rd;A 1 <br /> e. Rhisate Hauler and perodtted Treatment Storage&Disposal Pa ty: <br /> Hauler Name ere can Wity Wks4e, of sader itsiouftem# 7t <br /> Address—F—.0,Q 30 City e l �e 2b !S 3' <br /> Phone fie.(_- 0_0 <br /> Permitted Disposal Site i V L 0 -Fro-vi 5 <br /> EH 23 046 (Revised o8 IMS) Page 4 <br />