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RECEAN.JOAQUIN �ro''mF-Mith Department <br />COUNTY- OCT 10 2018 <br />�IFi�N�JTPeL HEALTHo. Tank/ ipingjDisposal �ite: AaIMPARTMENT <br />Address fi / W <br />® A - City _ Z$ <br />Phone No.( Bto G )—f4— <br />y�ci <br />EPA ID# (if transported to a permitted TSD facility)_ 1`0004 W 1 <br />9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES)4 NO j j <br />93. Descr in detail, h w the soil andfor water sample(s) beneath the tank and piping will be obtained: <br />01 <br />10. Desch?�hojr the excavation will be backfilled with suitable material upon remo al: <br />11. Handling of excavated soil: <br />a)material wit use o ' the tank Aver theelock ' ? <br />at w!!f t, <br />b) _tA!!Ib the at d+e�stinationot�ih ex avated to ill <br />c) Contaminated oil Hazardous Waste Hauler: <br />Name !�� 60 0' 1p'5- Hauler Registration # C.�I�� b 19 S �f <br />Address 1l' t j�l? ii✓� Ci`%�c City L w S __zip ?2(01 <br />Phone Number( a "" <br />12. What is the depth to groundwater? <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? YES[ j NO <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft• <br />Private Well <br />ft. <br />irrigation Well <br />ft. <br />Monitoring Well <br />ft - <br />Other <br />Other <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[X NO[ <br />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 ,prrarty must acknowledge this responsibility <br />�for thte billing by signature and date below. <br />Name L.� _- t+'Q c %GAS ' }— 016 .4[�\ <br />Mailing Address -92ST-42i, f 2i V�(�►�`-�}'�y != -p ( Q�%^7 Q <br />Day Phone Number (C3 ) � �i!4q — L l3® c/ �" � + v ° h V <br />5 of 10 <br />