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C. Tank/Piping Disposal Site: <br /> Name CCL6A4.1 k-+A4L4bRoP-4-- CrsN�/{Pd.l M 61.1'T/A•t.. <br /> Address 2-V%04> L► OP49*4 City oAcww7yNcK,Zip 4Z>*:2� <br /> Phone No.( e)4-0 ) X00• %2-4010 <br /> EPA ID#(if transported to a permitted TSD facility) Gam•R-c�ca 1 R�3 a <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 /> PV4--/S ^ 1 '/Z X to " 2wV-AdsCw INTL> 11+6 N AT1y E GPO1 L <br /> WGr toy6 !k GA.1p SyyP1 L,iri6L.93, 4. 11'b" tN CbOLOG t. WI►G8 <br /> 10. Describe how the excavation will be backfilled with suitable material upon removal: <br /> SrCGK Ill ..." ►'►'tit c'L_ q-0 ►t A�cF6GarE P•s�•'GEs W I trti-1 <br /> 'Voi conte Pi.G-n o� OR- I6P• �>z,•••v�4 <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit and cover the stockpile? <br /> 1-4 Z00% <br /> b)What will be the final destination of the excavated stockpile? <br /> GtrE+�tJ �-1��..'af-��i1ZG E:Ny lav 1•!M Ea.lTr.L <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name VWo1.4•441Q6 EtJV. '%PVC_ %t4 C_ Hauler Registration# �•��� <br /> Address 250711 'TCWNG CGF:*47 � City R�Nct � Zip�Z�i lO <br /> Phone Number( 0-M"LP ) 41.0• r"nGi <br /> 12. What is the depth to groundwater? t76PTIA Tb G.Ve'-J N p w00w� tS/•.QP Pro)4, to 1pe ET <br /> Describe the source of information: G. 11t, raE40/iq. MJ MON M P4@-A G. <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NO K <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 ([ NO[] <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 QC;TT VX— R-yA­1-J . 114 G <br /> Mailing Address Co?4"T '_ %90-t2-.416- GT. LO-^ • '��foPj <br /> Day Phone Number `7 55 5 <br /> P �6 c_r f' M�wJ�•CEiZ. 1(_-i/07/1 G <br /> Signature Title Date <br /> EH 23 046 (Revised 0712 5 <br />