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11 <br />1] <br />1. (a) <br />Is there a PHS-EHD contractor's questionnaire on file or enclosed? <br />YES Pq <br />NO [ ] <br />(b) <br />Is the current certificate of worker's compensation insurance on fale? <br />YES Pq <br />NO [ ] <br />(c) <br />Does the contractor possess a "Hazardous Substance Removal Certification"? <br />YES <br />NO [ ] <br />(d) <br />Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? <br />YES <br />NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES Pq NO ( ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />N/A Pq YES [ ] NO [ ] If YES, Permit 1* <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAPq YES[ ] NO[ 1 <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES (] NO <br />6. If tank residual exists, identify transporting hazardous waste hauler: <br />Phone # ( / ) .27/_15_ZVZ <br />7. DecontaminationProcedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES NO [ ] <br />b. Identify contractor performing decontamination: <br />I.m <br />Address <br />Y <br />i <br />-zix <br />Phone Q 9 ► <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite:: <br />,OM —A of a r/ h ri 1�e os rhos o, alb,esi t- 114 e u a m 9erAe GN <br />. / a_ <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Harrier Registration # / <br />Address /SE/� v ILX Cityg 1' eramrnl® Zi 71 <br />Phone No. L 3 / %5779'2! <br />Permitted Disposal Site Demeng t rc6 oA <br />5/20 <br />EH 23 046 (Revised 9/11/96) Page 4 <br />