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C. Tank/Piping Disposal Site: c <br /> Name a, nllk J Q !1 <br /> Address 1101 IaMW_y_6a_C City Ua 1lIIh �P �` ��U� <br /> Phone No.( C5 I U ) L' l L'l H 1 I 1 <br /> EPA ID#(if transported to a permitted TSD facility) TF� yy�y <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YESV NO[I <br /> 9a. D scribe,irldet ,howt s,> ar /or sam tus)egath the tank a pipin 11 be ob fined: <br /> t 1 Y 1 <br /> 10. Describe how the excavationSOl backfill with suitable materialupo val <br /> rem : <br /> �deg it Im ) <br /> y, . <br /> 11. Handling of excavated soil: <br /> a)What material will be usled to line @ tank pit and cover the stockpile? <br /> G. <br /> b) mat, I e tie fi <br /> Vnal desti ation of the excavated stockpile? <br /> �tz� �fid 2 Yi I - <br /> . 0�2113552.vy,-,vX <br /> c)Contaminated Soil Hazardous Waste Hauler. //--�� O[ <br /> Name p' 1�V1i V e TymnswyiM oy) Hauler Registration# wl 1 <br /> Address 39 Q-1 �'/TlraH60-100 lt�/t IC.O r�I(GZ� ,_city L L1��tlYVRS� zip 62 03l) <br /> Phone Number( ON 1 ) H60—100 IN n y r� <br /> 12. What is the depth to groundwater? ()! k)A '/�`J� VK.�_, <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NOX <br /> ® �+ TYPE OF WELLS DISTANCE TO TANKS(S) 1N31N1HVd3O H11V3H <br /> REC a ' tt -IV1N31NNO»IAN3 <br /> Public Well <br /> SEP 18 2013 Private well e. <br /> ENVIRONMENTAL Irri ation Well. tt <br /> HEALTH DEPARTMENT Monitorin Well tt. n�A13038 <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank($)? YES[] NOX <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 Tyiri it <br /> Mailing Address 1 J�I 1 W '}{ <br /> Day Phone lumber V ✓ <br /> Signature Title /Date <br /> EH 23 046 (Revised 10/30/12) 5J/ <br />