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• 0 <br /> C. Tank/PipingtDiisposal Site: d <br /> Name !`r C�.O.S00-E 1AJ PL'A1cf- <br /> Address City Zip <br /> Phone No.( ) <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 /> STE /t C-14-G D -TIE-c-41WCAL WOa Z JOL6 <br /> 10. Describe howt a gxcavation will be backfilled with suitable 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 will be the final destination of the excavated stockpile? VIA <br /> c)Contaminated Soil Hazardous Waste Hauler- —lY <br /> Name (V��f Hauler Registration# <br /> Address City Zip <br /> Phone Number f } <br /> 12. What is the depth to groundwater? <br /> Describe the source of information:sWr4C6 (��aT(LAcK�R CC�{sE SL 3?Z576.?61.6 <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 f7 ft. <br /> Private Weli (a�' ft. <br /> Irrigation Well ft. <br /> Monitoring Well a v ft. 09,7- <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[J 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 <br /> tt`he�billing by signature and date bellow. <br /> Mailing Address •C�""�'8X \C�� r �-� \ `�"t`��~•97Y!�S&3 <br /> Da �ho�ne Number <br /> Signature Title Date <br /> EH 23 046 (Revised 07/22/10) $ <br />