Laserfiche WebLink
C. Tank/Piping Disposal Site: �A\ <br />Address City Zip <br />Phone No.( 1 <br />EPA ID# (if transported to a permitted TSD facility) <br />9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YESA NO [ ] <br />9a. Describe, in detail, how the soil and/or water samples) beneath the nk and piping will be obtained: <br />p liYkl 0.�oa2�x P�d�+tt.1 ' ersl�tQs� �.�3 rh�P'�pc 1� ��.lP - cin: 1*3 11, 1 qI 5/1( -, (24114, <br />l4letilAl m rti- a 4,;,,laenm <br />10. Describe how the excavation will be backfilled with suitable material upon removal: N fk <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? N <br />c) Contaminated Soil Hazardous Waste Hauler: j <br />Hauler Registration #. <br />Address City Zip <br />Phone Number <br />12. What is the depth to groundwater? a5_ 524, yd o'A�� � � okat t�N 1119, oUin <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[ ] NO�ilf <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 &1 6( _ _ , /1 _ �gGWlJlalG, lel <br />Mailing Address°A�� z'� ®� <br />Day Phone Number Lg <br />Title Da e <br />EH 23 046 (Revised 8/1/11) 5 <br />