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• i i <br /> C. Tank/Piping Disposal Site: <br /> Namei�,2pe,� Si—.e1,2A ,.�n,,,, <br /> Address�Jpl osj 1; M1o61yCacLft city.0.Qy1d zip01H ( eo-i <br /> Phone No.( G l I n ) HI Lk ';011q /� s v �2 <br /> EPA ID#(if transported to a permitted TSD facility) CAL /Lo bw J X0 z <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YESpj, NO[] <br /> 9a. Describe in detail how the soil a or er sample(S). neath t e tank and piping will be obtained: <br /> Tgk Vt �1r)Qt�1�Ih �y YFA11i <br /> 10. D ieh w eexcavan will be backfilled wiqqsuVMpon mal: <br /> S6ri C1 M 0hn 1042 H-1 "I yl <br /> 1>r 'OYl <br /> 11. Handling of excavated soil: <br /> a) at material will be used to line the tank pit and cover the stockpile? <br /> wil. yIS00yum <br /> b)What will be the final destination o the excav ted st ? <br /> c) Contaminated Soil Hazardous Waste Hauler: �Y[` /Hler <br /> MIhkion c+ avi�im-pa <br /> Name istration# f9U I U raAAddress Zip <br /> Phone Number( ) <br /> 12. What is the depth to groundwater? ]S <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacen/pperlties? YES [] NOW <br /> TYPE OF WELLS DISTANCE TO TANKS(S) L <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation I ft. <br /> Monitori Well ft. <br /> 0th ft. <br /> 14. Will the tank(s) pendin losure be replaced with an aboveground or underground storage tank(s)? YES[] NOK <br /> 15. Indicate the respon le party to be billed for additional EHD staff time expended beyond 3 hour minimum <br /> permit payment tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner,the party ust acknowledge this responsibility for the billing by signature and date below. <br /> Name I 160 <br /> Mailing dressIMUY�alhG fl I W� <br /> Day P ne Number <br /> S gnature Title D� <br /> EH 23 046 (Revised 10/30/12) 5 <br />