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C. Tank/Piping[lDiisspoos�.al Site: <br /> ___. <br /> Name -a—�=' i;lr.O soa rL <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 oontractor (REQUIRED)? YES* NO <br /> 90. Describe,in detail,how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> Ga-W71) T"EUMVIE HeVEW777 <br /> 10. Describe how he excavation will be backfilled with suitable material upon removsk. <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit and Cover Me stockpile? N/L <br /> b)What will be the final destination of the excavated stodtpite? O <br /> c)Contaminated Soil Hazardous Waste Hauler:WA-Name Hauler Regiellration d <br /> Address City zip- <br /> Phone Number( ) <br /> 12. What Is the depth to groumm-aw PRp a7 <br /> Describe the source of InfbrmsGln:jV fkCff 66-6-rAACKER L�gsE ,S°L 3?2JC 3Eala <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [I NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well �d 4 ft. <br /> Irrigation Well ft. <br /> Monitoring Wap O ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)7 YES NO[] <br /> 15. Indicate the responsible party to be billed for additional EHD staff time expended beyond 3 hour minimurn <br /> permit payment per tank. If the party designated below Is different than the permit applicant,e.g. properly <br /> owner,the party must acknowledge this responsibility for the billing by signature and date below. <br /> Mailing Address •p�• �'�t, ��1 ..J ��� + '3 <br /> D orre Number {L'Sr ) 'S1�h� '�'� <br /> ��� � 1 �lJ�rt�. U�'�'1►��oa <br /> Signatu►e Title , Date' <br /> EH 23 046 (Revised 07/22/10) 5 <br />