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t , <br />t <br />1. (a) Is there a PHS-EHD contractor's and subcontractor's questionnaire on Me or enclosed? YES NO [ ] <br />(b) Is the current certificate of worker's compensation insurance on file? YES NO [ ] <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? YES WNO [ ] <br />(d) Has everyone on site, including cranelbackhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 8? YES [/NO [ ] <br />2. Has a "Site Health & Safety Plan" for this job site been submitted? YES [4111NO[ ] <br />3. Has applicant performing removal in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA [y" YES [ ] NO[] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NAdYES[ ] NO[ ] <br />5. Is there knowledge or evidence of leakage from the s) and/or piping? Of yes, please explain) YES [ ] NO [K <br />6. If tank residual exists, identify transporting hazardous waste hauler. <br />Name a <br />Address 2-55 P16�P-4.. F—p_ <br />Phone#('5l0 ) 2�5S - <br />Hauler Registration # CO i c:�) <br />CA - <br />city Rtc� <br />VAMo0, zip ,)+}$O 1 <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? <br />b. <br />C. <br />Identify contractor performing decontamination: <br />Name V4 E -N 0-F � SD S �A—r, (J --n 0 0 <br />YES [ ] NO N/ <br />INc.. <br />Address 9��1 D� C� Cf�"" =��- L�t� - city` J�;,zy13, G',.zip �521 <br />Phone No. n( <br />Describe method to be used for decontamination: <br />• �U�t�t. PvRG� �.aAvGT �,i�C`J �-�j �ITg-v�n�N. �oJ`/-C�.Pp�-�1 <br />!,.n <br />--r- f, ­4P c ry E t L ► LL aT=- Co t. ez-r e o SY j4e,"C) C lPy m P A t-4 <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />l�vf�,L FA -S 1. W4A'r'af;;-�- r\ Ft F, I X16-, , Sume5 `-WZF.Z_Wc.4 kit U_ <br />t� GtoR-�s� I� PROc��`�`.`� Lr4F!;,a_l to DR.vM At4o Ea PO`r'C� <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility- <br />Hauler <br />acilityHauler Name -r-- . C, 1 _ Hauler Registration # <br />Address "_SF2� (� .. �-�� city momzip �I4 wC t <br />Phone No.( '5 l (7 <br />Permitted Disposal Site `,,.Z <br />EH 23 046 (Revised 08113199) Page 4 <br />