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1. O Is there a PHS-EHDn is questionnaire on Me or enclosed? YES [ NO[ ] <br />(b) Is the current certifleate of worker's compensation Insurance on file? YES [ O [ ] <br />(c) Does the contractor possess ti R YES [V]' NO [ l <br />2. Has a • for this job site been submitted? YES[ NO [ l <br />3. H 8 t performing removal In a City of Tracy obtain a' va Permit'? <br />p <br />N/A I I NO I] If YES, Pe it <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ YES [ l NO[ ] <br />S. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES[ l NO <br />6. If tank residualexists, identify transporting hazardous waste hauler; <br />Name Hinder Reghdration { �m-I 5--qL- <br />Address . R Ctty Zips _ <br />Phone# (_ C_ _) 75 ° l cl — LA- 4 4 4 <br />7. Decentambudim Procedures: <br />a. Iffill () and pipingdecontaminated or to removal? YESI N I I <br />b. Identify or performing decontamination-. <br />Name mo i- c— <br />Add s . ;� J� f 1 v City Zip <br />Phone No. 1 -_ ± 1 <br />C. Describe methodused for decontamination: <br />d. Describe how risate material will , sto onsite rior to manifesting offsite. + <br />e e V-. <br />e. Rinsate Hauler and permifteil Treatment, Storage & Disposal Facility: <br />Hauler Name 1 va Hauler Rcgb&ation # <br />Address City Zip <br />Phone No. ( ) 7 <br />Permitted Disposal Site <br />Page 4 <br />