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1. (a) Is,there a PHS•EHD contractor's and subcontractor's questionnaire on file or enclosed? <br />(b) Is the current certificate of worker's compensation Insurance on file? <br />(c) Does the contractor possess a "Hazardous Substance Removal Certification"? <br />(d) Has everyone on site, including crane/backhoe operator, been certified <br />to work on hazardous waste site in accordance with CCR Title 87 <br />2. Hasa "Site Health & Safety PIan" for this job site been submitted? <br />3. Has applicant performing re oval in the City of Tracy obtained a "Grading and Excavation Permit"? <br />NIA I I YES ( I NOK If YES, Permit # <br />YES[] NO[] <br />YES I ] NO <br />YES VNO <br />YES eNO ( J <br />YES K'N0 [ j <br />4. Has the contractor obtained approval from the local fire department to perform tank cutting? NA[ J YES[ j NOI-4-11 <br />5. Is there knowledge or evidence of leakage from the tank(s) and/or piping? (If yes, please explain) YES [ ] NO (� <br />G. If tank residual exists, identify transporting hazardous waste hauler: <br />Name %C 1 Hauler Registration # <br />Address 2 5 S £. City &e"I 471019 ?Ap� t� <br />Phone # ( S/ Z5 /3 93 <br />Decontamination Procedures: <br />a. Will tank(s) and piping be decontaminated prior to removal? YES RINO ( J <br />b. Identify contractor performing decontamination: <br />Name ,CG I <br />Address 2 5 5" P /? /Z /3t o City l-cl rWo&) zip 9460/ <br />Phone No.( 37/ y ] ? 3S- / 3 2 3 <br />C. Describe method to be used for decontamination: <br />d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br />1?/N5,i rE Wl e G ,ria i" &,C .s �_ CLO QA2 S2 rd' <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name %r'G ,� Hauler Registration # 0/2 <br />Address Vol City R Zip 9 8U/ <br />Phone No. ( fZO 1323 <br />Permitted Disposal Site /���/G c�9G ZO$% E19Y RD_ eAAZ -(-b <br />EH 23 046 (Revised 08/13199) <br />Page 4 <br />90 39dd a001d H1dId 660689b60Z 10:60 0002/!i/50 <br />