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0 <br /> C. Tank/Piping Disposal Site: <br /> Name <br /> Address SMS <br /> Lia City �.. zcl 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)? YE NO[] <br /> 9a. Describe,in detail,how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> 10. Describe how the excavation will be backfil d with suitable materiajupon removal: <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit and cover the stockpile <br /> d� c <br /> b)What will be the fin]destination of the excavated stockpile? %®` �%e ®Z IS CT <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name 1)111,14,0 A&IO % Hauler Registration# <br /> Address C 60 City-EX") Zip <br /> Phone Number 1: <br /> 12. What is the depth to groundwater? Z <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 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[] N <br /> O <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 ` <br /> Mailing Address 12— - ���,� � �� ,r �✓� - <br /> Day Phone Number ? ) <br /> Title Date <br /> EH 23 046 (Revised 8/1/11) 5 <br />