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TR JKS 'Tt�-YGgf�S�CV.4S' % 4 J /+I£.Ji / LZ, l S. —/c74 4£ 1ZOA!) 77." L cC C/1. 9Ssf1/ <br />0'V AF (2-0`!) lvE -93rD rg� (zoi) (G5' �3 !z <br />C. <br />s%CEG 'rai•v,t <br />9a. <br />10. <br />11 <br />12. <br />13. <br />14. <br />15. <br />/—ii3C1s'S/3rjjCTrFD�Zi✓AdUi�+/c. y999 5 F}�/S7/•J�2o9Ji,,�N1fl-9 GA. <br />ng Disposal Site: f'M ,�E (zo 9) y�� -N L 59r <br />SCNit/17-LC/Z S7 -,e=t=/ 1 i1oJuCi f <br />Address_/ -Z 0DD =0/coin 3Zal3 city C`d41A2j%o zip S 2 - <br />Phone <br />Phone No.( y/G 1 /.T 5 - l%�'/U I *+--� V <br />EPA ID# (if transported to a permitted TSD facility) 1_S 11cry(// <br />Is the sampling firm an independent third party from the contractor (REQUIRED)? YESX NO[) ` � �d- <br />Describe, in detail, how the soil and/or water sample(s) beneath the tank and pipinq will be obtained: <br />how the excavation will be backfilled with suitable material upon <br />Handling of excavated soil: <br />a) What material will be used to line the tank pit and cover the stockpile? <br />//'i4Ct34(, 1JLAS;i <br />b) What will be the final destination of the excavated stockpil#? /r S TOCK ?Ie r is <O -J iAr�/.N9TEv <br />A DtCiS/On/ iIASED LrJ'e47S <br />c) <br />c) Contaminated Soil Hazardous Waste Hauler. <br />Name S�V/da'%//)Vr-"/Zyz Hauler Registration # <br />Address PO AOX 5-29 City S yl20A) cl zip <br />PhoneNumber(�_ <br />What is the depth to groundwater? <br />Describe the source of information <br />Are there any water wells on this parcel or adjacent properties? YES[ ] NO <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />R. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitorinq Well <br />R. <br />Other <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] N0b( <br />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 <br />Mailinc <br />Day Phone Number ( ,?-,/ <br />64,W C -1C xc 3 <br />Sign re Title Date <br />i <br />EH 23 046 (Revised 10/30/12) 5 <br />ILL/.SIO/-S <br />600 �7/ <br />