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SANJ O A Q U I N Environmental Health Department <br /> - COUNTY --- <br /> c. Tank/Piping Disposal Site : <br /> Name N/A <br /> Address City Zip <br /> Phone No . ( ) <br /> EPA ID# (if transported to a permitted TSD facility) <br /> 9 . Is the sampling firm an independent third party from the contractor (REQUIRED) ? YES [ ] NO [x] <br /> 9a . Describe , in detail , how the soil and/or water sample(s) beneath the tank and piping will be obtained : <br /> N/A <br /> 10. Describe how the excavation will be backfilled with suitable material upon removal : <br /> N/A <br /> 11 . Handling of excavated soil : <br /> a) What material will be used to line the tank pit and cover the stockpile? <br /> N/A <br /> b) What will be the final destination of the excavated stockpile? <br /> N/A <br /> c) Contaminated Soil Hazardous Waste Hauler: <br /> Name Hauler Registration # <br /> Address City Zip <br /> Phone Number ( ) <br /> 12 . What is the depth to groundwater? <br /> Describe the source of information : <br /> 13 . Are there any water wells on this parcel or adjacent properties? YES [ ] NO [x ] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> j Private Well ft. <br /> I <br /> I <br /> Irrigation Well ft. <br /> I <br /> Monitoring Well ft. <br /> Other ft. <br /> 14 . Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[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 Walton Engineering <br /> Mailing Address PO Box 1025 , West Sacramento , CA 95691 <br /> Day Phone Number ( 916 ) 373- 1165 <br /> 5of10 <br /> I <br />