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1 0 0 <br />(ADC Tank/Piping Disposal Site: L1 DC J <br />Name po x -Lf l � ,ft 1 t- 11l <br />Address CI (I m (�. Oyabn t�City �f� fZip <br />Phone No.( Sbq , -Z+r�% �7 0 <br />EPA ID# (iWansported to a permitted TSD facili *y- <br />9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES NO [ ] <br />9a. Describg. in de� ail how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br />��I <br />10. Describe how the excavation will be backfilled with suitable material upon removal: <br />11. Handling of excavated soil: <br />a) What material will be used to line the tank pit and cover the stockpile? <br />WA <br />13. <br />b) What will be the final destination of the excavated stockpile? <br />c) Contaminated Soil Hazardous Waste Hauler: <br />Name—A6 6 Van(`f'(a Ohmic -I Hauler Registration # I <br />Address (Z�&Clcis lel � p CitZip J � <br />Phone Number /� <br />What is the depth to groundwater? Ap(c-y �1, f6 b? l elo `ar-A ce ti yyrb . <br />Describe the source of information <br />Are there any water wells on this parcel or adjacent properties? <br />YES [I NO [y <br />FTYPE 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 <br />�ac nowledgge�this responsibility for the billing by signature and date below. <br />Name � Y �(.t.t ��� Z --M e�' r--\ <br />MailingA rens _4k <br />I <br />Day PhTe <br />N tuber(_ <br />Signature <br />EH 23 046 (Revised 07/22/10) <br />0 9 -41' / - <br />E <br />Date <br />YES[ ] NO[ ] <br />