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C. Tank/Piping Disposal Site: <br /> Name -5'r14 Mi SILL Z' ySco <br /> Address//0/,6� Yca daro dl �/A/4(ca City /�jc.,a L✓ocrr.°y4ip/C �aT CfS�S.S�O <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)? SK NO[1 <br /> 9a. Describe in detail,how the,soil and/or water sample(s)beneath the tank and pi ing will be tjained: <br /> Cc,nT4,-I N Cj <br /> t <br /> 10. Describe how the excavation will be backfilled with suitable mterial upon re oval: <br /> cc t�Lc %6 G I J CA un Glco� <br /> n <br /> 11. Handling of excavated soil: <br /> a)What ateria wil�be usedto line the tank pit and cover the-stockpile / / /r <br /> y. .faliU �!+ /G �Ti.v �h�l Uz.✓ GN LL <br /> Iw <br /> b)What will be the final destination of the excavated stockpile? <br /> ,i GJC <br /> c)Contaminated,/Soil Hazardous Waste Hauler: <br /> Name Y Hauler Registration It �� ( <br /> Address City Zip <br /> Phone Number <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel r adjacent properties? YES)( NO [] <br /> TYPE OF ELLS DISTANCE TO TANKS(S) <br /> Public ell ft. <br /> Pri to Well ft. <br /> h ation Well /' ft. <br /> XMonitoringWell / - <br /> Other ft. <br /> 14. Will the tank( pending closure be replaced with an aboveground or underground storage tank(s)? YES[] NO'X <br /> 15. Indicate th responsible party to be billed for additional EHD staff time expended beyond 3 hour minimum <br /> permit p ment per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, a party must acknowledge this responsibility for the billing by signature and date below. <br /> No -7011 <br /> l Mi c✓' / <br /> M ling Address .dalfi ,`,rr <br /> Day Phone Number 7 � ) 9-cVIC 916 0 <br /> // Z-F <br /> /-7 <br /> Signature Title vDate <br /> EH 23 046 (Revised 10/30/12) 5 <br />