Laserfiche WebLink
C. Tank/Piping Disposal Site: <br /> Name l//LL/ /yJf�G- /2lAit/�f'�.'/Zs.E✓�T G <br /> Address /?O �f/�Cy)t /Z.���1�F/City ,r.�G Zip <br /> PhoneNo.( ) �yS�_330 Gf s L jr/6 /�9� Zs- <br /> z'-EPA ID#(if transported to a permitted TSD facility) <br /> i <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES[] N0,W- <br /> 9a. Describe, in detail, how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> �!� O llL .GGriF.✓i�O f�7le/!h�✓ 743�iJ <br /> /J stolr sriJ.✓/>/�r/IiLL .�:- <br /> 10. Describe how the excavation will be backfilled with suitable material upon re oval: <br /> ' 7wo fAGLc rrd✓o �/cv 4.tr �-7, �OG G ! ?" dei0✓�i <br /> ���y Ouif-(r2= .t�_T.aw/l /�jJStiz�l�.oi�1Ti�N <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit and cover th stockpile? <br /> itlU ._,f�<Lc�P/�+t✓ � lid /, .v%/' .�s✓ /�.'L✓�t1 <br /> b)What will be the final destination of the excavated stockpile? <br /> .wN <br /> c)ContaminatedHazardous Waste Hauler: <br /> Name �j/L Hauler Registration <br /> Address O, dox City F ~ 'r Zip !252 <br /> Phone Number( �l� 1 99�, Q1?'73 <br /> 12. What is the depth to groundwater? ,1API lvO�A_z /6 �v�✓ Z�i3 Rii1..✓l-J <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) "�r C ]VIE <br /> Public Well ft. <br /> �rrtV • n M11� <br /> Private Well ft. <br /> Irrigation Well <br /> TA!NFA!TM <br /> Monitoring Well n. n PARTMENT <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[] NdXr <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 C-�.��a.t/ GD.✓✓yY�—/+S��i—1 , l,�tvt <br /> Mailing Address 'G/jg a C%/!Q /�i�LGG� `J' �,2. �p G✓ /?C �j��/Z <br /> Day Phone Number <br /> Signa ��`/G, Title Date <br /> i <br /> EH 23 6 (Rev' 10/30/12) ,5 <br />