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9. <br />9a <br />10 <br />C. Tank/Piping Disposal Site: <br />Address City <br />Phone No.( ) <br />EPA ID# (if transported to a permitted TSD facility) <br />Is the sampling firm an independent third party from the contractor (REQUIRED)? <br />Describe,, in detail, how the soil and/or water sample(s) beneath the V k and pipit <br />Zip <br />YES <br />will be obtained: <br />M IS163/I1 . <br />Describe how the excavation will be backfilled with suitable material upon removal: ti f k <br />11. Handling of excavated soil: W/ <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? (U!A- <br />c) Contaminated Soil Hazardous Waste Hauler: W/A- <br />Address <br />Phone Number ( ) <br />City <br />Hauler Registration #. <br />NO[] <br />tS tl Nic/t(, <br />12. What is the depth to groundwater? a5- JLC 4, b%sea 0'A 4, oui <br />Describe the source of information: � <br />13. Are there any water wells on this parcel or adjacent properties? 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)? YES[ ] N(X' <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 , e 6J61 eE1J-lalGr lel e' <br />Mailing Address <br />Day Phone Number Lg <br />Title Dade C, <br />EH 23 046 (Revised 8/1/11) 5 <br />