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LJ <br />C. Tank/Piping Disposal Site: <br />• <br />City 1 Zip <br />Phone No.( ) ✓ <br />EPA ID# (if transported to a permitted TSD facility) O1►'G, (,T0 7 u ' <br />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 />10. Describe how the excavation will be backfilled with suitable material upon removal: <br />11. Handling of excavated soil: Kf A <br />a) What material will be used to line the tank pit and cover the stockpile? <br />b) What will be the final destination of the excavated stockpile? <br />c) Contaminated Soil Hazardous Waste Hauler: <br />City <br />Phone Number <br />12. Wh the depth to groundwater? <br />Dd'scribe the source of information: <br />Hauler Registration #, <br />92 <br />13. Are there any water wells on this parcel or adjacent properties? YES [ I 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 />ft• <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 below. <br />Name \A MAI <br />fN J'1 ( <br />Mailing Address � C900 / �= � � C � � <br />qf'troncNumbeY (L �� )�is L- �l � � 6 <br />, <br />Title Date <br />EH 23 046 (Revised 07/22/10) <br />