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1. <br />2. <br />3. <br />4. <br />5. <br />51 <br />7. <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 Plan' for this job site been submitted? <br />YES <br />NO [ ] <br />YES] <br />NO [ ] <br />YES ,M <br />NO[ ] <br />YES P] <br />NO [I <br />Has applicant performing removal in the City of Tracy obtained a 'Grading and Emcavation Permit? <br />N/A [ ] YES [I NO [I If YES, Permit # <br />Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES N NO[ ] <br />Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO <br />If tank residual exists, identify transporting hazardous waste hauler. � p �r�r EZ� <br />Name <br />C � �/ (A� 1� �� lam `' HAW, R� 31F'' r'3"4-5_�S_' 3� <br />Address _Bcl -�® A777&t_4 i; S7-rL- _-T" I City �Zip 91(o -z- I <br />Phone # ( Z'l Q ) 3 — <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES [)� NO [ ] <br />b. Identify contractor performing decontamination: <br />Name <br />J PC_ <br />Address 961 '2,0 IU315 4 5TRer7- (�, City XL&,JL-, Zip C/'/ (, L l <br />Phone No.( S-10 ) (n —C) 41 <br />C. Describe method to be used for decontamination: <br />Tit 1 IAC L'-('`1+.J�a' 4- 612Y XC[_ <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />(til wo i eLnnm ®tj Srrl- Td Af.) R ff rwyo-b TsJ') •>= <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name'SOV 1 �,)t, Hauler Regisiraitioi� # ""2w-"':' <br />Address Be%o AOy" 14 City ®!' 4af4-t )b Zip 2 462 <br />Phone No. ( .S-) D ) L3 <br />Permitted Disposal Site <br />Page 4 <br />