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S A N J O �{ Q I vI I N Environmental Health Department <br /> — C O U rN-tTAY—v <br /> CA TanklPfping Dispo at Il : •�� � <br /> nn4 ` S ✓ n <br /> Name oC I � 4 j co <br /> Address �� <br /> !r � <br /> Phone No. tot - <br /> EPA ID# (If transported to a permitted TSD facillly) <br /> Am is the sampling firm an Independent third party from the contractor (REQUIRED)? YES 44 NO [ I <br /> ga. Describe, In 1g11} seihandforwa sa erI ts) beneath t Q k aapipi gwill b o7r�d: .� <br /> AAA <br /> 10. Describe ho>w excava ' -C 1l he backfilled with suitable me erial upon removal: �SY <br /> 11 . Handling of excavated soil: <br /> a) whalmate - Iwillbe sedtolln !h tank pit and cover the stockpile? <br /> G . <br /> b What wJ the nal destl anon of a excavate styc�p e? 1 <br /> .yt � 'S hd i� F5 <br /> c) Contaaml1na1e�d�SoilHarrdpous aste Hllar: <br /> Name �-N" `�d� 'V'a ,�M`cj� ' W`Pi1/���Hauler Regtstration8 �](%� <br /> Adtlress -� - •1j'-�i7 - City Vlr7 � _Zlp '1r• � <br /> Phone Number (_ �Z <br /> 12. • What is the depth to groundwater? ,.. 'l�Yl '�o.&M <br /> Describe the source of Information: <br /> 13, Are them any water wells on this parcel or adjacent properties? YES [ ] NOK <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well JL <br /> Private Well ft. <br /> Irrigation Well R. <br /> MonitorInq Well <br /> Other ft. C , <br /> 14- Will the tank(s) pending closure be replaced with an aboveground or underground storage tank($)? YES[ ] NO(J{ <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 a party designated below Is different than the permit applloant, e.g. property <br /> owner, the patty must sake <br /> Name edge this responsibility for the billing by signature and date below. <br /> [ <br /> Malllng Address <br /> Day Phone Number ( ) <br /> 5oflo <br /> I <br />