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1. (a) Is there a PHS-EHD contractoes questionnaire on file or enclosed? YES NO [ ] <br /> (b) Is the current certificate of worker's compensation Insurance on file? YESA NO [ ] <br /> (c) Does the contractor possess '? NO [ ] <br /> 2. Has a Wte Ekalth&Safety PIW for this job site been submitted? [ ] O [ ] <br /> 3. Has acant performing removalIn a City of Tracy obtain a "Grading and ExomMm Permit'? <br /> /A I NO [ I If YES, Permit <br /> 4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA [ ] NO[ ] <br /> S. Is there knowledge or evidence of leakage from thetank(s) and/or piping? (If yes, please explain) YES [ ] NO [] <br /> 6. If tank residualexists, identify transporting hazardous waste hauler. <br /> - <br /> Name Hauler Registration# <br /> Address City. Zip . <br /> Phone # <br /> 7. Decontamination Procedures: <br /> a. VVIII (s) and pipingdecontaminated or to removal? YESOK N C ] <br /> . Identily contractor performing decontamination: <br /> Name l N 11,AC,.. <br /> Address PO DO)< l (o_7 City Zip <br /> Phone No.L C1 i ) 42[ -- L9 cf O <br /> C. Describe methodused fordecontamination: <br /> V® Wt l t <br /> d. Describe how rinste material will be stored onsite prior to manifesting offsite: <br /> t tJ�'aLgiw C> ICS= SA6rr_4A.)M <br /> 1�'"l✓ 1 <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> auler a �t tU6CEVIcW Hauler Registration# <br /> Address 0. ROX II -1 City Zip <br /> Phone No. <br /> Permitted isosl Site <br /> Page 4 <br />