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1 � s <br /> C. Tank/Piping Disposal Site: <br /> 1 Name Not applicable <br /> Address City Zip <br /> 1 Phone No.( <br /> EPA IDA(II transported to a permitted TSD facility)CAC002678515 <br /> 1 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES F0 NO(] <br /> 9a. Describe,in detail,how the soil and/or water sample(s)beneath the lank and piping will be obtained: <br /> 1 TMaW Yom it alis Wiu lvil,viii)O aFnalN,unp♦ExlbablM Oipgpb lM1t a14 rNt APSI iecM1iranvil Mn waaMMawar rb btl 45 iapaeaelM Dbed <br /> tlg IoM b a0bn Pe aoi,aiaamnN VN Iwik TM Oarpa wi YsoanpYtsorr m exA wl of M VST <br /> 1g. Describe how the excavation will be backfilled with suitable material upon removal: <br /> 1 Stockpiled materiel will be covered with Visqueen. There will be no tank pit as it Is an abandon in place <br /> 11. Handling of excavated soil: <br /> 1 a)What material will be used to line the tank pit and cover the stockpile? <br /> Stockpiled material will be covered with Vrsgueen. There will be no tank pit as It Is an abandon in place <br /> 1 b)What will be the final destination of the excavated stockpile? <br /> Fa,wara LmBi <br /> c)Contaminated Soil Hazardous Waste Hauler. <br /> 1 Name Ali Chem Disposal Hauler Registration M 2914 <br /> Address 21 Great Oaks city San Jose ZIP 95119 <br /> 1 Phone Number(4'08 )499-5274 <br /> 12. what is the depth to groundwater? 50 to 60 feet <br /> Describe the source of information: <br /> 1 Amendl,gbgaOhaGH.Wnwmonbhg Mbaaudba papMy.TM nio, Tb gi0wgMln is Oeiween i0bE0 Yat <br /> 13. Are there any water wells on this parcel or adjacent properties? YES2NO() <br /> 1 TYPE OF WELLS DISTANCE TO TANKS(S) '`"`� "�' <br /> Public Well <br /> ' Private Well ft. �.� <br /> Irri anon Weit ft. <br /> 1 <br /> Monitodng Well 171 ft. <br /> Other ft, <br /> 1 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[] NOQ <br /> is. 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. properly <br /> owner,the parry must acknowledge This responsibility for the billing by signature and date below. <br /> 1 Name Mr. Frank Poss, PSI <br /> M��ing saar Tidewater Avenue, Suite B, Oakland, CA 94601 <br /> 1 Day/fone umber. . 10'�434-9200 <br /> _Department Manager 10/20/11 <br /> 1 Signature Title Dale <br /> EF123046 (Revised S;'l+'I1) 5 <br /> i <br />