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C. Tank/Piping Disposal Site: <br />Name Clean Harbors <br />Address 1021 Berryessa Road City San Jose Zip 95133 <br />Phone No.( 408 ) 441-0962 <br />EPA ID# (if transported to a permitted TSD facility) US EPA ID No. CAD059494310 <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 />See attached work plan for direct push soil sampling <br />10. Describe how the excavation will be backfilled with suitable material upon removal: <br />No proposed excavation <br />11. Handling of excavated soil: <br />a) What material will be used to line the tank pit and cover the stockpile? NA <br />b) What will be the final destination of the excavated stockpile? NA <br />c) Contaminated Soil Hazardous Waste Hauler: 350 b <br />Name Clean Harbors Hauler Registration # <br />Address 1021 Berryessa Road City San Jose Zip 95133 <br />Phone Number( 408 ) 441-0962 <br />12. What is the depth to groundwater? 40 feet below surface grade <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? <br />14. <br />YES [)I NO[ ] <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />>1,000 <br />ft. <br />Private Well <br />>1,000 <br />ft <br />Irrigation Well <br />>1,000 <br />ft. <br />Monitoring Well <br />>1,000 <br />ft <br />Other <br />>1,000 <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NOS <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 David Catanzarite <br />Mailing Address 7373 West Lane, Stockton, Ca 95210 <br />Day Phone Number ( 209 ) 4 <br />:: s istant Chief Engineer <br />Title <br />EH 23 046 (Revised 8/1/11) 5 <br />09/24/2012 <br />Date <br />