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1. (a) Is there a PHS-EHD contractor's questionnaire o file r enclosed? YES [41' NO [ ] <br />(b) Is the current certificate of worker's compensation Insurance on rile? YES [vj' NO [ ] <br />(c) Does the contractor possess a Mazankws Substance Removal Cerdacatiou'Y YES [yi� NO [ ] <br />* 2. Has a 'Site Health & Safety Plan' for this job site been submitted? YES [V� NO [ ] <br />3. Has applicant performing removal in the City of Tracy obtained a 'Grading and Excavation Permit'? <br />N/A J, YES [ ] NO [ ] If YES, Permit # <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] YES[ ] NO[b]/ <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 eadsts, identify transporting hazardous waste hauler: <br />Name S O R- Z Y1 4 V S+ 12 1 c S Hauler Registration #-Q O 3 S <br />Address f? O. b o x q,I 4 city (,U . S at C• Zip 95- 6 9/ <br />Phone # ( 7/6 ) 3 2' 02 - -2 3 Z-2- <br />7. Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES C 1 NO [ ] <br />b. Identify contractor performing decontamination: <br />Name OJ► iC- G IS tE Vti VI C. <br />Address e> C> X 15- city P i rge qh+ rrroy C Zip 9'S -4<Q'8 <br />Phone No.( 9/6 ) 6 S s - 3 / 8 / <br />C. Describe method to be used for decontamination: <br />P(to CJEA'-"-) a'z—_ <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />T <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: ' <br />Hauler Name Q O 2 e n d us -+V- t c S Hauler Registration # 0 0 35 - <br />Address <br />5 - <br />Address P o, 13 ox iia city CUzip <br />Phone No.( %/� ) 3 �' �/ - .3 /e%-2 <br />Permitted Disposal Site c5 T A T C 6l1 / dC M Z'/7-749 <br />a 6/3 S. Mq/i2 -3,e� 4o6 Atiyr/c5-, C.a, 9006/ <br />Page 4 <br />