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0? -' 14 14: 44 FP0V T-014 P00041"001" F-01� *� <br /> C, Tavk/Piping Disposai Site: / 2 Z� <br /> Name 1 <br /> HEP, H <br /> Address_„__1 �t�� c,_r 5 ._.._, city < tJ C ..r tom+-zip �` �NTA�- <br /> Phone No( L{ ^ pEPA TM �T <br /> EPA IST#(if transported to a pemAtted TSD fae itity) <br /> g. Is the sampling firm an independent third party frons the contractor (REQUIRED)? YES lid NO(] <br /> ga Descdbe, in detaii, how the soil andfor water arr� ie(s)beneart the Irk end aping wilE be tainedf J <br /> � ��• i �.[- � T <br /> 1{t: Desuibe flow the excavation will be backfilled with suitable material upon rerrtov0 <br /> t irr 1c_ i- F- W rte..° '' - C A la+t/Vti. <br /> 11, Hendlln of exCaveted soil d rer <br /> a)Wht a rnateriat willo used to line the t ik pit ar d cover th stockpil <br /> IV_ r -� (? , r � ",Q thr { <br /> r�bd1'OWtZ <br /> b)What will be the final destination of the xe avated stockpilef ww c <br /> r,f <br /> c <br /> c)& a foil F artltusVkMste Ha'ufu,, ` <br /> ttmt <br /> fi <br /> C � [ r'li ar ,Transportatign Regastra i.oA #3500 <br /> Mot r Carsiier Perm #O1$$�48 <br /> Address- <br /> ° 1 v . G cty dip s �CJJ <br /> �,, I <br /> Phone Number L�� r 1 ;L�4 <br /> 12. What is Me depth to grorrndwater? ,� - Z 5'�� b, (o r�1_ / � :� S�r �SAL-4- // <br /> aescribe the source of information: G{ v ill VV(A tM ova i 1" 1 (' "- 2�{ y, r• L <br /> I 4Ye fr�nr. ,� <br /> I Ar?there any water wells on this parcel or adjacent properties'? YES [I NO <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well €t <br /> Monitoring Well C1 C2 ft, <br /> Dthar ft. <br /> 14. 011 the tank(s)pending dosure bo replaced with an aboveground or kniderground storage tarxk(s)? YESj} NCJ) l <br /> 15, Indicate the responsible parry 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 roust acknowledge this responsibility for the bitling by signature and date below. <br /> Norrie T (/f-yl Pfd - aYl —fry C-4 J9 r? <br /> PABillrtp Adtirc 5 ek <br /> Day Phone Number <br /> rqu.aMr <br /> ut'�r e <br /> Tony L. Walters:.��, <br /> Stu <br /> RH 23 046 (r wised 10/30112) . <br />