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SAN JOAQUIN <br /> Environmental Health Department <br /> COUNTY - . . _. <br /> c. Tank/Piping Disposal Site : <br /> Name NA - Decommission in place <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 {x] NO [ ] <br /> 9a . Describe , in detail , how the soil and/or water sample(s) beneath the tank and piping will be obtained : <br /> See attached WGR Southwest work plan . <br /> 10 . Describe how the excavation will be backfilled with suitable material upon removal : <br /> Clean inert tank and lines will be filled with 10 sack controlled density sand slurry <br /> 11 . Handling of excavated soil : <br /> a)) What material will be used to line the tank pit and cover the stockpile? <br /> NA, decommission In place . See work plan for managing drill cuttings . <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? Unknown . If encountered it will be sampled . See work plan . 20 If' . <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [ j NO K] <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[ ] NOS(] <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 Ray Smith - Nustar Terminals Operations Partnership L . P . <br /> Mailing Address 3505 Navy Drive , Stockton , CA 95203 <br /> Day Phone Number ( ) 209 -943-5662 ext. 5516 <br /> 5of10 <br />