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a) Is there a PHS•EHD contras tionnaire on file or enclosed? YES [X] NO[ ] <br /> b) Is the current certificate of worker's compensation insurance on file? YES [ ] NO[X] <br /> c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES [ ] NO[X] <br /> 2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [X] NO[ ] <br /> 3. Has applicant performing removal in the City of Tracy obtained a"Grading and Excavation Permit"? <br /> N/A[X] YES [ ] NO[ ] If YES,Permit# <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? <br /> NA[X] YES [ ] NO[ ] <br /> 5. Is there knowledge or evidence of leakage from the tank(s)and/or piping? YES [ ] NO[X] <br /> (If yes,please explain) No.=Amodix C <br /> 6. If tank residual exists,identify transporting hazardous waste hauler. <br /> Name WA Hauler Registration # <br /> Address _ City Zip <br /> Phone No. ( ) <br /> 7. Decontamination Procedures: <br /> a. Will (s)and piping be decontaminated prior to removal? YES [ ] NO[X] <br /> b. Identify contractor performing decontamination: <br /> Name N/A <br /> Address City Zip <br /> Phone No. ( ) <br /> c. Describe method to be used for decontamination: <br /> N/A <br /> d. Describe how rinsate material will be stored on-site prior to manifesting off-site: <br /> N/A <br /> e. Rinsate Hauler and permitted Treatment,Storage&Disposal Facility: <br /> Hauler Name N/A Hauler Registration # <br /> Address City Zip <br /> Phone No. j ) <br /> Permitted Disposal Site <br /> 4 <br />