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RECEIVED <br /> C. Tank/Piping Disposal Site: MAR 10 2016 <br /> Name ///V l�G-'-,�r`� 5�� l�/ZU(��C/� � RON MENTAL <br /> .- r��c�eQT���t��T <br /> Address /���P /CC7 L S©ey /p���/�city J/(/�Pd/I- Zip �5 � <br /> Phone No. <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES,jj��� NO[] <br /> 9a. Describejn detail, how the soil and/or watersample(s)beneath the tank and piping II be obtaineffd: <br /> cw - iLl u✓i«"Ae �1 i <br /> 72X,,--7/�&A 771�—r <br /> 10. Describe h w the excavation will be backfilled with suitable material upon removal: <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit and covert stockpile? <br /> moi« ,c3 lip-cy �C�� <br /> lFTh��Srac.� /sic£ /S �w�-s�i-✓�4i�, <br /> b)What will be the final destination of the excavated stockpile? <br /> c)Contaminated Soil Hazardous Waste Hauler. <br /> Name 0/Z L.Pz�� "�/C��o,��s,✓��1� Hauler Registration# <br /> Address/' �r �� O y� l Z��J City Zip <br /> Phone Number <br /> 12. What is the depth to groundwater? C� / <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO ]'j <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well V ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft- <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[) No <br /> 15. Indicate the responsible party to be billed for additional EHD staff time expended beyond 3 hour minimum \\ <br /> permit payment per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner,the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name <br /> Mailing Address /��/�/ ` 0-3)3 <br /> Day Phone Number ZO C' 36 <br /> I c3 <br /> Z�c <br /> Signature Title Date <br /> r-u"�'l r%A-' lD....:--A i�nnMnICN � <br />