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SAO <br />JAQUIN <br />COUNTY---- -- <br />C. <br />- € _ `iED <br />Environmental Health Department <br />Phone <br />EPA ID# (if transported to a permitted TSD facility) T RJ00G 7 <br />9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES)j NO I) <br />9a. Descrlpq, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br />10. Describp oj�the excavation will be backfilled with suitable material upon rem at: !� <br />11. Handling of excavated soil: <br />a) at material W11W useOjio W the tank Aver the fork ' <br />12. <br />13. <br />�✓ /1 ®g v+ <br />at il�tRh�Ae�f;adestina�iion�o!ihavatedV� ]►tocp( leL b)Nk <br />c) ContaminatedSoil Hazardous Waste Hauler: <br />Name 71f IA <br />V; -P + Hauler Registration # <br />Address l�t�`G 1 �rCity L f4 S! Zip <br />Phone Number( <br />What is the depth to groundwater? <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />YES [ ] 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 />Monitorinq Well <br />ft. <br />Other <br />ff• <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES 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 betow. <br />Name Lf- ,GAS—IL/aAtA AJAV <br />Mailing Address <br />Day Phone Number <br />5 of 10 <br />s t <br />- <br />