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On <br />C. Tank/Piping Disposal Site: <br />N./ <br />Address CityZip <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 [ ] NOX <br />9a. Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br />10. Describe how 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 cover the stockpile? <br />b) What will be the final destination of the excavated stockpile? <br />c) Contaminated Soil Hazardous Waste Hauler: <br />Name Hauler Registration # <br />Address City Zip <br />12. <br />13. <br />Phone Number ( ) <br />What is the depth to groundwater? <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />YES [] NO[] <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />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 E�1M7 l!'�7 iJeyllN,/ /; t� ��/ • �G� <br />Mailing Address a aggqdnnn/CCC `W R rIG/�mvoI <br />Day Phone Number) r"1 <br />pWAIAE®2 <br />Signature Title Date <br />EH 23 046 (Revised 10/30/12) 5 <br />