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1. (a) Is there a PHS-EHD contractor's questionnaire on rile or enclosed? <br />(b) Is the current certificate of worker's compensation Insurance on file? <br />(c) Does the contractor possess a "Hazardous Substmee Removal Qxtilication"? <br />YES [ l NO [ l <br />YES[] NO[l <br />YESf] NOH <br />2. Has a "Site Health & Safety Pian" for this job site been submitted? YES [ ] NO [ ] <br />3. Has applicant performing removal In the City of Tracy obtained a 'Crading and Ea mvatlon Permit'? <br />N/A W YES [ l NO [I If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAf-�YES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) I'ES [ ] NO l/ <br />6. If tank residual exists, Identify transporting hazardous waste hauler: <br />Name OIL- AyaGuU M — Hauler Registration _ <br />Address �o4&� SKI-T+A-1,1S- City NeyvAL7=14- Zip '?44-'('0 <br />Phone # ( 2LD ) 7Ir-2 • �L4oa <br />7. Decontaminat1km Procedw �^ <br />a. Will tank(s) and piping be decontaminated prior to removal? YES ] NO F <br />b. Identify contractor performing decontamination: <br />Name 1 T5FP, ICr, ( <br />Address City r'liZ-[ LNZ ZIp 9�7'�� <br />Phone No.( 32Z '1120 <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />- nkM'% -Tr4 w1619!9nL&-. 1M114 VAe--tdJAMIS'l7 LIQ= & TSNle=aiZ ZM"r . <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name t-145-B&WO-q 09L VA.( I&VM Hauler Registration # <br />Address 0tri1J '�L—Mt-V�k1y.. city guli►r. p <br />Phone <br />Permitted Disposal Site q40 !MA74 A14t:F' 00VA4r-V-- 416 - <br />Page 4 <br />