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SAN.JOAQUIN RE C- E tEllth Department <br /> COUNTY-- OCT 10 2018 <br /> ENVIRONMENTAL HEALTH <br /> c. Tankr/ tJqDIS Sal te:. rh 1'0 EPARTMENT <br /> Name <br /> 11 Mao, <br /> Address <br /> City Zip <br /> Phone No.( 901— <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 Y NO[ I <br /> 9a. Descrlb#,In detail,h the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> 10. Desai tp hoWthe excavation will be back!!. wllh suitable material upon re <br /> at: <br /> 48 W <br /> 11. <br /> Handling of excavated soil: <br /> a)wat material wit use <br /> p the tank d ever the lock s- <br /> wro' tan <br /> b) at 'It the f al destination of t ex avatede ile <br /> toe <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name tew vl',f DA iiq,,� Hauler Registration <br /> I-A <br /> Jo-A- - GLmLrec,tv Jf4a4��51i Zip p <br /> Phone Number( 9 1 1b <br /> 12. What is the depth to groundwater? 411A <br /> Describe the source of informafion:---T---V- <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 <br /> lrr' atlon Well <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES X NO[ I <br /> is. Indicate the responsible party to be billed for additional END 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 LC &9:2nJ1%Clo—S — to-(� <br /> Mailing Address-32V--)Q-1 9q <br /> Day Phone Number CSnK5---J—!70(4.- 130 CtC C OA, <br /> 5 of 10 <br />