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t' I` R C 1 <br />1. (a) Is there a PHS-EHD contractor's questionnaire on file 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 Mazardous Substance Resioval Certification"? YES[] NO[] <br />. Has a Wte Reaft & Safety PIW for this job site been submitted? [ ] NO[] <br />3. Has applicant performing removal In the City of Tracy obtain a "Grading and EkeavationPermit"? <br />1A [ ] NO [ l If YES, Pe it <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ ] [ ] NO[ <br />�J <br />s. Is there knowledge or evidence of leakage from thetank(s) and/or piping? (If yes, please lain) ] NO [ <br />r: If tank residualIdentifyA:. 1hazardous�. <br />7. <br />Name Hauler Registration # <br />Address city ZIp <br />Phone #( ) <br />Decontamination Procedures: <br />U <br />IM <br />a <br />2 <br />VVIIJ (s) and pipingin r to removal? YES f11NO[ ] <br />PZ =1 A <br />Address city Zip <br />Phone <br />Describe method s fordecontamination: <br />PLs . S P - S" ; <br />Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />Rinsate Hauler and permitted Treatment, Storage & Disposal l+'acility: 'o. <br />Hauler Name Hauler Registration# <br />Address city ZIp <br />Phone No. ) <br />Permitted isposal Site <br />Page <br />