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SAN - <br /> 1 n A n � I l �I Environmental Hafth D�parftnent ,F, { <br /> — C O UU N IT�YV I—f , L�e� {Fish, <br /> FED 0 7 2018 <br /> c. Tank/Piping Disposal Site: `y, �, <br /> � L�f.'7�l1CY =.� t._.- ' \ ► �CJ�, �� C�i! jV V i �. ��U�ENVIRONMENTAL HEALTH <br /> BETARTMENT <br /> Address �� � � �`J City lY <br /> Phone No.( � <br /> EPA ID# (if transported to a permitted TSD facility) '5!21i0 ` 7 <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES )dC NO <br /> 9a. Describe, In tail how soil and/or ter m !Q(6 b neat the tank i to will b, tained= <br /> .+Sc._`-� C��7�7 �-��V �i CiC7L� <br /> 10. Describe how e e cava i ill lite w suitable m terial on r o I: <br /> 0 n c C. d, <br /> 11 . Handling of excavated soil: <br /> a) What mat 11 be yW to li the ank pit an�cover kpile? ! ` <br /> r� NAAi L' `7 Ietf Y' t a L Yiy �,vr�� 4z- <br /> ✓ e. <br /> b) What will ba al destination of th excava d 5 pie? v <br /> '� cc/yiW- VV.Tld 0 , yt . sal +ref <br /> c) Contaminated Soi(Hazardousler: <br /> c ` <br /> Name ilrx.xi 1J1t1 1r �4'>?7 Hauler Registration OL. <br /> c� ��7 S ,�^ <br /> Address t7�c'J`") ?( 4"'f✓ i1' 1 Cityi SYTi��NWi1l�1�GZip <br /> Phone Number ( �517) ra22! - 12;Y9� <br /> 12, What Is the depth to groundwater? l! <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 DISTANCE TO TANKS(S) <br /> Public Wel( ft. <br /> Private Well it, <br /> Irrigation Well it, <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[ ] NCk <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 acknowled ethiisr�eippoigsibility for the billing by signatt endd'aatte`bgellow. <br /> Name -C�V'L �"��C$$f1 Vi/1''� �^7"�L"' �1 (J--Sr'ZC..t•`-- CC/`%�'� 1�`�-- <br /> Mailing Address f� � ` 1`y , " r ��C7 � . `--e" I <br /> Day Phone Number ( ot ; ,J <br /> 5of 10 <br />