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c. Tank/Piping Disposal Site: j <br /> Name_ lh& 5 <br /> _ Yy y <br /> ladCtl"r'8&__ �- tG+ts! its' _ Zip _ L . <br /> EPA its#(if transported to a permitted TSD facility) CA'> <br /> 8. is the sampling firm an independent third party from the contractor (REQUIRED)? YES,W NO[) <br /> t7a. Describe,to detail,haw the sail a Tawatecr8ample(st�enoath ttank and ptpinwtll t�obtained:_avAl 41f 1 <br /> i. _ .a Cly wt.o� <br /> C7a cribs hw t a sx vati n will be bac fitted 'th suttabie mate l upon rein"' t: t <br /> A10 vef-e <br /> #r 1 4a A ?'� t , <br /> 91. andling pf1axcave d sat(: <br /> a)V l;at(t alerial will be use to ine th ion it and cover ilia tockpiie? <br /> (f T <br /> b)VAi witl be a s(nal stina i the a eva d sto ile? t� <br /> 6{7,atf OA5r`5 t7rS Gt f �E�( a , Coll !P( 1, /V <br /> c1 antamsnated Loii 1-1zard"us Waste H u[at: J <br /> Name Vt ' t h d ' , itC Hauler Registration <br /> Address �� k a e e,r �5 i� _�_�. City_ r_---• .__zip ems t?' <br /> Phone Number t '.LLL <br /> �F&'L% -gall iz <br /> 12, What is the depth to groundwater? � '"" � - � ^�, fwJkk <br /> Describe the source of Information; <br /> 43. Are thara any water wells on this parcel or adjacent properties? YES (1 NoAr MAR <br /> jA <br /> TYPE OF WELLS DiSTAN.Ck TO TANKS(s) <br /> roti .. <br /> Public Welf <br /> Private'Vdeii <br /> trrt�atian fltteil� _•,_,.�it. , <br /> lvlanit"rittq VJeJI __ ft. _ <br /> 3 <br /> Other <br /> 94. Will tha tank(n)ponding ctosure be.replacad with an aboveground or sinderground storage tank(s)? . YC-S0 j NO <br /> 15. Incl►date the responsible parFy.•to be billed far-additlon.al EHD staff time expended beyond 3 hour minimum <br /> pemYR payment per tank, if Ind psrty d8r.1gribled below Is dirf&eht than the perMit.l.PpliCartt,a.g, property <br /> owner;the party must aGkriowlerJge this responsibilityfae the billing by signaWre and data below <br /> Name <br /> ivt Il'ing Address _ t t'`( 0( q _ <br /> D y hone i bar <br /> p <br /> Si, furs Title v Date <br /> Y=T_7';Z fl,�f. t`Ruvir,.a,1 trit;nil?1 `t <br />