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SANN J O n Q I I I N Environmental Health Department <br /> -- H- CO U NHTI�Y --- - - 1 <br /> C, Tank/Piping Disposal Site : See SJ EHE Fres <br /> Name <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 K NO [ ] <br /> 9a . Describe , in detail , how the soil and/or water sample(s) beneath the tank and piping will be obtained : <br /> Soil samples will be collected via soil boring drilling in the area of the former UST, refer to the attached <br /> Soil Boring Permit and related documents <br /> 10 . Describe how the excavation will be backfilled with suitable material upon removal : <br /> Will not be any excavation activity <br /> 11 . Handling of excavated soil : NOT APPLICABLE <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? <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? 12 . 5 feet bgs , Source : Closed LUST site , 1245 W. Charter Way , Stockton , CA <br /> Describe the source of information : <br /> 13 . Are there any water wells on this parcel or adjacent properties? YES [ ] NON <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <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[4 <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 Margo Bentz Ivers <br /> Mailing Address 4750 Lagorio Rd , Stockton , CA 95215- 1811 <br /> Day Phone Number ( 209 ) 483 -7285 <br /> 5of10 <br />