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M 0 <br /> C. Tank/PipingaDiisposal Site: d� <br /> Name N�A O Sy(l rL ��'•P���' <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 /> c941) EcaKM(e-A L WM <br /> 10. Describe hot Q�ccavation 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? N/A <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name (y_/fT Hauler Registration# <br /> Address City Zip <br /> Phone Number( ) <br /> 12. What is the depth to groundwater? A010AOX, 4 EO <br /> Describe the source of information:SW(ZC6 Gov°T(tAe1G�R C.CASE .S'L. 9-7Z576,;.2.6 <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 t7 ft. <br /> Private Well (d a ft. <br /> Irrigation Well ft. <br /> Monitoring Well O ft. <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 the billing by signature and date below. <br /> Mailing Address •q� 8`Zt. `T L� 1 �� � t��- � <br /> Day <br /> PhoneNumber <br /> Signature Title Date <br /> EH 23 046 (Revised 07/22/10) 5 <br />