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I. (a) Is there a PHS-EHD contractor's questionnaire on file or enclosed? YES M NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES [gyp NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES J(J NO [ ] <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES U NO [ J <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES X1 NO ( ] <br />3. Has applicant performing removal in the City of obtained a "Grading and Excavation Permit"? <br />N/A K YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAN YES[ J NO[ J <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ J NO P <br />6. If tank residual exists, identify_ transporting hazardous waste hauler: <br />Name 4/ ®.c.l' 1 ° Hauler Registration # ® 4,344 <br />Address P ® ° / % 75- city— Zip 95.7 7 & ^ /6 7 <br />Phone # ( S'3 ® <br />7 on i res: <br />W k(s) and piping be decontaminated prior to removal? YES J4 NOAL 21 1 <br />[ j <br />�-.t Vi � �L��_-;,"ailo.,OtiftBqqtTpltor performing decontamination: <br />PERMIT % k VIC ' � <br />Name _ <br />Address 2,53 . QA . City Zip 9-:5;L0 � <br />Phone No.( a o 1—) 41ol — % 3.3 7 <br />C. Describe Method to be used for decontamination: _&UM4,A,- <br />A A n ._[L_ <br />71 <br />rinsate <br />to <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />r <br />Hauler Name Hauler Registration #�3 <br />Address I, ® , -7,57 City Zip <br />Phone No. <br />Permitted Disposal Site_&-� �L ® /(vl.�%� ° ° gsg'�-3 <br />C b D 5 90 (o 9 q l ®3 5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />