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1. (a) Is there a PHS-EHD contractor's questionnaire on Me or enclosed? YES [ ] NOK <br /> (b) Is the current certiflcate of worker's compensation insurance on Me? YES [ ] NOX-T, <br /> (c) Does the contractor possess a Hazardous Substance Removal Certifiaation'? YES [ ] NO NL <br /> 2. Has a 'Site Health&Safety Plan'for this job site been submitted? YES [ ] NO <br /> 3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Rumvation Permit" <br /> N/A O YES [ I NO [I If YES, Permit# <br /> 4. Has the contractor obtained approval from the local bre department to perform tank cutting? NA[)`YFS[ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NOX/ <br /> 6. If tank residual exists, identify transporting hazardous waste hauler: CPfL 9 Z 17642-�37 <br /> Name Et?(C V'.S0t'3 Haub Registration# <br /> Address255 0A IM t ip. , City KICNMNO Zip 94WI <br /> Phone# ( (t7 ) "235 1393 <br /> 7. Decontamination Procedures: <br /> a. Will tank(s) and piping be decontaminated prior to removal? YES X NO [ ] <br /> b. Identify contractor performing decontamination: <br /> Name <br /> Address _. _ City - ... Zip <br /> Phone No.( <br /> C. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to .manifesting offsite: <br /> F <br /> e. Rinsate Hauler and permitted Treatment, Storage &Disposal Facility: <br /> Hauler Name eP'1CILS Hauler Registration# NYNQ_1%-coto I 12 <br /> Address 25S e6A E, BL\w , City RICH NOW Zip '14601 <br /> Phone No. <br /> Permitted Disposal Site C I� <br /> Page 4 <br />