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VW <br /> C. Tank/Piping Disposal Site: ) <br /> Name ! P(� <br /> Address 900 a&'W r) City Zip (� <br /> Phone No.(,"10 ) Cf 44 — I S 's- <br /> EPA <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 NO[] <br /> 9a. Describe, in detail, how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> ►, Q r--- <br /> 10. Descrilye ho/w7 the excavJation will be/,backfilled with s�j)Iitable material upon removal: <br /> 11. Handling of excavated soil: <br /> a)What material will be,used to line the tank pit and cover the stockpile? <br /> b)What i <br /> ll be the final estiRation of the excav ed stockpile? n <br /> NXh <br /> I A;nd 'll <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name /-443 ; ay J�� C Hauler Registration# , <br /> Address � In j�6�,'� �� Tib CitAS, /�:t 4 D'i-i Zip <br /> Phone Number(d 1) _) 9 ga n <br /> 12. What is the depth to groundwater? ?q�,e�� y' 1=e zocr d S' <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) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[] NON' <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 /> l <br /> Name q--8 �—q <br /> Mailing Address �(� %to �/ (�1 ! 6�"',_l <br /> D hone Number �U ) �_ CC D (C. <br /> ignature Title Date <br /> EH 23 046 (Revised 10/30/12) 5 <br />