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• • RECEIVE® <br /> r <br /> Tank/Pi in <br /> c. Di FEB 2 6 2014 <br /> • p g Disposal Site: <br /> Name fin]}z-Gr St-O-.,1 ENVIR TAL ' <br /> SIO\ W�Ni �YV11bitiVCaC -40 C Q—a-t- hd Mt +�TMENT <br /> Address ' J .r� 11 rty U Zip- <br /> Phone <br /> Phone No.( �to ) U LI H =7�' 1 <br /> EPA IM(if transported to a permitted TSD facility)r NTC)5012 X 52 <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES' NO <br /> 98. D scribe,irl.detail,h w the soma or water sam ie(s) eneath the tank pipin ll be ob fined <br /> f Y <br /> 's <br /> 10, Describe how the excavation w yy backfill with suitable material upo rem vol: <br /> lmyn -F-- cuo-h SbJ� ( Dlylb/Ar ()h T V'W I1M�tYt�e� <br /> 11. Handling of excavated soil: <br /> a)What mater al w 11 be u d�to Gne�1,1tq�(tank pit and cover the stockpile? <br /> UJS_OfT�__U?1 j <br /> b) at 'I(J?e t e final desa a excavated stockpile? <br /> 1 t Yt� C/� € <br /> c)Contaminated Soil Hazardous Waste Hauler. ° 0�S^21tp3� 5S�'U�,vX <br /> Name QiD� il/IIY3i TtrDlhs rizttiOh Hauler R}eggistration# 3301 <br /> Address 25y 22. T1FA.yi1 )C O�yl�rlri�• Cily _f1LilM—gyp "I - 03�) <br /> Phone Number(—OHI) L%U—100 <br /> 12. What is the depth to groundwater? U h)�OtA h 0'-*- In <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES I] NOX( y <br /> 6; <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> 1N�tn`Jkdd�!7 FI>;"Ih'�t4 <br /> Public Well ft <br /> SEP Ib N13 r <br /> - Private Well ft. £60� .^d, � d-1•; <br /> - Irri ation Well, ft. 4p pp <br /> Monitoring Well ft. <br /> Other I ft. Y <br /> 14, Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[J 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 TyirltiL <br /> Mailing Address 1 i Y r. <br /> • Day Phone lumber (DZ 1 �� ✓ I <br /> UN � 13 <br /> Signaturerite Date <br /> EH23 046 (Revised 10/30/12) 5 <br />