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• <br />C. Tank/Piping Disposal Site: LADC J <br />0 <br />�1�-t"I <br />Address ci99 S. AD-Afl �ld City • gA- zip <br />Phone No. q ) Jq 0 <br />ansported to a permitted TSD facility) <br />Is the sampling firm an independent third party from the contractor (REQUIRED)? YES [ NO [ ] <br />9a. Describgg `�in detail how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br />H1111/ kilraer <br />10. Describe how the excavation will pe backfilled with suitable material upon removal: <br />lip Ma Man <br />11. Handling of excavated soil: <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 />RcContaminated Soil Hazardous Waste Hauler: <!—� <br />,�c� <br />('(41 Ume 1 1- Hauler Registration # tea`/ <br />�) 'l5 UQ <br />�j7 Address C /011- ',\'I ACLS l ilii i _ City P.i°�Q`��� zip <br />Y1 ' ,�U1 Phone Number( ) W2- T= <br />W1 What is the depth to groundwater? Anrrm 4 hpl #ln 791'rhfl n- r, -Adlo <br />(� 13. <br />I l�, <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />nuV b s <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 />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)? <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 ac nowledge this responsibility for the billing by signature and date below. <br />Name / � .5 <br />Mailing A res 04 vx('m O <br />Day Ph e N mber 17- <br />AA <br />7- <br />/ lc halollrl ll <br />Signature Titl Date <br />EH 23 046 (Revised 07/22/10) 5 <br />YES[ ] NO[ ] <br />