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1. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES [x] NO I ] <br />(b) Is the current certillcate of worker's compensation Insurance on le? YES [x] NO [ ] <br />(c) Does the contractor possess on"? YES[xJ NO[ ] <br />2. " for this job site been submitted? YES NO [ ] <br />3. Has applicant performing removalIn the City of Tracy obtain a "Grading and Rmcsivation Permit"? <br />N/A E4 YES [ I N [ I If YES, Permit# <br />. Has the contractor obtained approval from the local fire department to perform tank cutting? NA [A [ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the n(s) and/or piping? (If yes, please explain) YES k] NO [ ] <br />See Kleinfelder's attached report <br />6. If tank residualidentify transporting hazardous waste hauler; <br />Name Erickson, Inc. Hauler Registration # <br />Address -255 Parr Blvd. City Richmond ZIp 94801 <br />Phone #( 510 ) 3 9 3 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminatedprior to removal? YES NO bd <br />- b. Identify contractor performingdecontamination: <br />Name N/A <br />Address City Zip <br />Phone o.( <br />C. Describe methodto be used for decontamination: <br />N/A <br />d. Describe how rinste material will be stored onsite prior to manifesting offsite: <br />N/A <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility:. <br />auler Name N / A Hauler Registration # <br />Address City Zip <br />Phone No. t ) <br />Permitted isosal Site <br />Page <br />