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i <br /> SAN 10 A Q U I N Environmental health Department j <br /> ---_ --COUNTY- <br /> T n?KS' cv/CGE �.►S r'oS£i� 6F= i?T uJ_ S 7 AOR S7f fAt7 i►°rr��.v7 <br /> c. Tank/Piping Disposal Sitio. /Z al $ad T,1 TArCNe2 !2m'9`P �"� ``���e-dcle e'9`9' 5-3 srD <br /> ;� (47rledff-0) <br /> tJame / <br /> '�i'`�G a/rct 13£ )'yp�or+9? !a0/ZLc�if�2j) . 'Ti9.t> jtCiL`�N1 <br /> I <br /> Address �'�� SD�r� !/)�!/N l�I�-1� City /)Z4/V7_F4f_-4[p 25'734 <br /> Phone No.( `�24 91 I <br /> A r <br /> EPA ID#(if transported to a permitted TSD facility) ��°e�Gl <br /> i <br /> 9. is the sampling firm an independent third party from the contractor (REQUIRED)? YESk NO[ ] <br /> 9a. Describe,i detail h w the soiland/or wate sample(s)b neath the tank anpiping will be obtained: S,ylYJ/�1� �✓!�� B� <br /> �Ao� �� 4 <br /> 10. Describe how the excavation will be backfilled with suitable material upon re orl: DC <br /> GR dEG ' <br /> S£'Cr <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? <br /> 6�1,�/T pic/� l RiQ<s') �++.,j i.+f A!!?�e/.e�7 B/�CGY�I%D/�71.�/�4%lDit/44?ec <br /> C)Contaminated Soil Hazardous Waste Hauler: <br /> Name /Hauler Registration# <br /> Address �D Q'v J� Jd 7 , - - CI 13 1J /2t7r�/ Zip q 7 J <br /> Phone Number c <br /> 12. What Is the depth to groundwater? �� �D �Z� Ci/✓l D� f jyG �DN f <br /> Describe the source of information <br /> 13. Are there any water wells on this parcel or adjacent properties? YES[ ] NO <br /> i <br /> i <br /> r <br /> PE OF WELLS DISTANCE TO TANKS(S) <br /> blic Wellvate Wellgation Well • i <br /> Monitoring Well ft• <br /> Other ft' �N`t7 t UAL ir9n1/'�7'> <br /> 14. WIII the tanks)pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] N0 <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 <:;;?rl)Er A (1-'ta2 [�' <br /> Mailing Address 4&7-30 //moi c N �c '� /r�C�;0A <br /> Day Phone Number <br /> w <br /> i <br /> _ I <br /> Ot f0 <br /> I <br />