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' May -23 , 2003 2 : 52PM GI r Environmental No•0371 P. 3 <br /> 1. (a) Is there a PHS-EHD contractor's and subcontractors questiowalre on file or enclosed? YES H No l) <br /> (b) Is the current certificate of worker's compensation insmanee on file? YES N NO[) <br /> (c) Does the contractor possess a'HaUrdaus Mkauee Itemovoi certification"? YES W. No I) <br /> (d)Has everyone on site,including cmelbackboe operator,been certftfea <br /> to work on hazardous waste site Ill accordance with CCATitle 8? YES N Nall <br /> 2. Has 2 Mte Health&Safety Plan"for/this job site been submitted? y�g K NO[) <br /> 'Sa�2� ?(r-, )? w <br /> n - �iC.3iT 'PJ45•-C1'f'D ..A�'1P�dl..a2 i.r.""� lkp� fboy � �fY.c.Z.-� ) <br /> 3. Has applioaut performing removal in the city of Tracy obtained a*&aft and Excavattan readt"? <br /> N/AX YES I I NO I) if YES. Permit N z- a-�1-mac(• <br /> 4. Has the contractor obtained approval from,the local fire department to perform tap&wrttorNA()7*011 <br /> 5. Is there knowledge or evidence of leakage from the taak(s)and/or piping? Pt yes,please explain)YES p), NO)) <br /> lb <br /> �2 S <br /> 6. If tank residual efts,identify transporting hazardous waste basler. ` <br /> Name .+i Healer Re B 5 <br /> Address 3L(ao (he., s.. � 4- <br /> Phone#( <br /> 7. De <br /> IL s)and piping be decontamigated prior to removal? YliS g NO j) <br /> b. identify contractor performing deeon tion: <br /> lv$me M -E 1,smrsn 4-, <br /> g `LA, <br /> Address 3 City f 3 c �w� I e� MP <br /> Phone Nola r' •• ,� 4 o Sa 45.,-- __ ._ �. <br /> C. Describe method to be used for d®con ation: <br /> Tin K. r' <U ✓%% <br /> d. Describe llw rfasale material will be,stored onsite prior to manif , offs! <br /> 60C, <br /> VA JG <br /> e. Rlnsate Hauler and pa d Treatment,Storage 8c Disposal Facility: <br /> n� z <br /> Hauler <br /> Address O &I c,.� s r City lc.@�s its /C 7dn 9 <br /> Phone No. <br /> � Permitted Disposal site �fos� � CCS, -6r}�,� �p.,t (�}Q�c.� ��/t Cra��a2.��o5D(j <br /> M 23 046 (Revfsed 08!13/9.9) page 4 <br />