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' C. Tank/Piping Disposal Site: <br /> Name Not applicable <br /> ' Address City Zip <br /> Phone No.( ) <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES [] <br /> ' 9a. Describe,in detail,how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> TMWkk mthasldaol Nelankwlkbeeacavaledueinga0 khOWNebaseol Nalankalalael.APSIIe IM nwlll Nanuseahen0 auger.M Onll a5 a,...1 Vh asa or <br /> Ne 4nk w oblaln Ne wll uMamaelh Na lank. Two borings wW be complete oM on each eM al Ula UST <br /> ' 10. Describe how the excavation will be backfilled with suitable material upon removal: <br /> Stockpiled material will be covered with Visqueen. There will be no tank Il as it is an abandon in lace. <br /> ' 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit an7be <br /> stockpile? <br /> Stockpiled material will be covered with Visqueen. Thernk it as it is an abandon i lace.b)What will be the final destination of the excavate <br /> Pending a as-Soil wit b ramov to a subabla bndae <br /> C)Contaminated Soil Hazardous Waste Hauler: <br /> ' Name Pending Analyses <br /> H ler Registration# <br /> Address City Zip <br /> ' Phone Number( ) `✓ts n <br /> 12 What is the depth to groundw4parcelor <br /> feet <br /> ' Describe the source of inform / <br /> kx,lMmem gwellseNlWlMpmpedy nN.XMatetauntgmundwa%rbbalween W,.6olaal <br /> 13 Are there any water wells on tent prop ies? YES ] [J 0/TYPEDI ANCE TO TANKS(S) , <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitorin W I 171 ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closu be replaced with an aboveground or underground storage tank(s)? YES[J NO(Z <br /> 15. Indicate the responsible rty to be billed for additional EHD staff time expended beyond 3 hour minimum <br /> permit payment per tan . If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must cknowledge this responsibility for the billing by signature and date below. <br /> Name Mr. Fra Poss, PSI <br /> ' Mailing Addres 703 Tidewater Avenue, Suite B, Oakland, CA 94601 <br /> y Pho tuber(51 ) 4-9200 <br /> Department Manager 10/20/11 <br /> Signa tyc Title Date <br /> EH 23 046 (Revised 8/1/11) 5 <br />