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L <br /> 1 <br /> C. T . ng D <br /> i <br /> Add <br /> Nam <br /> Zrp► <br /> Phone No. <br /> A t (if transported to a permitted TSU Wily) <br /> 9. is the sampling firm an independent third party from the contractor (REQUIRED)? YES NO Nev <br /> 9a, in detail, le(s)beneath the tame and piping will be Obtained' <br /> 10. Describe how thepxc:_%yafionwill with . ►e l u nreat: <br /> 11, Handling of excavated$+oii. <br /> a)What material will be to tine the tank Pit and cower the stockpile? <br /> b)What will be the final ` of the excavatedstockpile? <br /> c)Contaminated SodN r s Wastis Hauler <br /> Hauler iii # <br /> City- <br /> Phone Number <br /> 12. What is the depth to groundwaterli <br /> Describe the source of information: <br /> 13. any water weft on this parcel or adjacent properties? ! YES [ NO[) <br /> TYPE OF VVELLS DISTANCE TO TANKS(S) <br /> Public Well % <br /> Private Well ft. <br /> Irrigation l ft. <br /> Monitoring ll ft <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replacedwith an aboveground or undeMround storage tank(s)? YES[) <br /> is Indicate the responsibleparty to be billed id l ENO 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 p must acknowledge this responsibility for the billing by signature and date Wow. <br /> NOn <br /> ddr <br /> � � t <br /> y f'h r ` <br /> Cl <br /> « <br /> Title Date <br /> F,1123046 (Kevi .d tOF36fff2) S <br />