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C. Tank/Piping Disposal Site: JJLL <br /> Name �e'Zlf /�fL /L//ftfr/fL�Ti�/ <br /> Address/30 Wee,14 /oC f( rfn�f City_S'oor-ehe.r!• Zip 9S8// <br /> Phone No.( 9/6 // e% ' 6&1 ?f7 • 55-X6 - Dwr✓rdfk/ro� �•yr <br /> EPA ID#(if transported to a permitted TSD facility) Z41A 00 A 7T ,f 1 <br /> 9. Is the sampling firth an independent third party from the contractor (REQUIRED)? YES[] Nt <br /> 9a. Describe, in detail how the soil and/or ater sample(s)beneath the tank and ppiping will be ob ined, <br /> •� ' Q•t esfd.STe ♦/iJ/s�e/ w.rf T I ♦G� r p4 G •�� <br /> O • I i CA U ♦ ! r f I d Ct-1d6q <br /> 10. Describe how the excavation will be backfilled with suitable material upon removal: <br /> WO G/C ,0" L OrG L'L^t G/./ �e�✓Qc/s j <br /> 11. Handling of excavated soil: <br /> a)What material will be used to I' a the tank pit and cover the stockpile? <br /> 01 <br /> b)What will be th final destination of the excavated stockpile? y4tr°% r�' e Cl'♦w/¢•r6•rr l3♦.1nrs�. /�, <br /> S./' }a e' e ofSu w ra aSt - :s r TI Cpwr /Ae/•fJa� <br /> �voN- <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> /faneir«r N e - e / Se"0 'a <br /> /Vin-/{7z NameHauler Registration#- <br /> o /A~j^ O/ <br /> Al-04 Z- Address Ea. 9- City`// Oe le5 Zip <br /> Phone Number( /G ) -O <br /> r <br /> 12. What is the depth to groundwater? ko i w 7 G <br /> Describe the source of information: (neo - 7r elre.- r Airec e RYJ.( So)/ ,Qwrr f .✓e✓. d o/3 <br /> 13. Are there any water wells on this parcel or adjac t properties? YES [] NOX C <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Wel ft. <br /> Irri atio ell ft. <br /> Mon' rin Well ft. <br /> er <br /> 14. Will the tank(s)pen � g closure be replaced with an aboveground or underground storage tank(s)? YES[] Nup� <br /> 15. Indicate the res onsible party to be billed for additional EHD staff time expended beyond 3 hour minimum <br /> permit payme per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner,the rty must acknowledge this responsibility for the billing by signature and date below. <br /> Name «- GGJ�v <br /> Mailing Address 3lea 1+y0� !�-Z <br /> Day Phone Number( /�b ) O rL� /q1l0p <br /> 7 �1���iYF' resit S<i✓_A/CR 9-Z1 SFSe <br /> Signature Title Date <br /> EH 23 046 (Revised 07/17/14) 5 <br />