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r-1 „ <br /> iii , i 1 <br /> . :.J <br /> i <br /> i <br /> c. TanIdPiping Disposal Site. E <br /> Name . r . 'r2 S7"� L tr} ,rc-�,� E <br /> CJAddress �0 ® 0© yzQoy /Za city zfp <br /> Phone No.( !?14 ) '" 1 0 � <br /> i <br /> EPA ID# (if transported to a permitted TSD facifity) j <br /> 9. Is the sampling firm an Independent third party from the contractor (REQUIRED)? YE^PNO [ ) <br /> 8a. Der e, in detail, how the soil and/or water sample(s) beneath the tank and pi in will b Ined:: \\,�dly[ �' <br /> 4 <br /> ! deznr <br /> 10. ❑ scribe how the excavation will be 4 ckfiiled with suitable material upon removal <br /> IF <br /> Ir <br /> 11 . Handling of excavated soil: Sole n? /�L/9G�p ®� a .0T/a 04�Gz 1140p5p <br /> a) Whet malerial will be/used to fine the tank p and coove�r a stockpile? <br /> b Wh t will be the final destiation of thexcav d s le? 4pn <br /> c) Contaminated Soil Hazardous Waste Hauler. <br /> Name Hauler Hauler Registration # WZ 7 / <br /> f <br /> Address /tet ��,x� .7p� /3YlaeA cit3f, ZI CY i <br /> PhoneNumberl � t� /"�l� <br /> / <br /> M What is the depth to groundwater? <br /> Describe the source of Information: K4071 45V40S ,J fe , <br /> 13, Are there any water wells on this parcel or adjacent properties? YES NO [� j <br /> ! � i! <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well <br /> Irrigation Well ft. C <br /> Monitoring Well ft. <br /> Other ft. j <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ J NO[ <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 idling by signature and date below. <br /> Name rr��_- -�^ -- --- � .• t( <br /> Mailing Address G©�® `� , � L7�/' � � 7 2! ecie';a t <br /> q <br /> Day Phone Number r i tl/�4—` � �® 7� 7� Z,C9, 2w <br /> $= oF- ry <br /> 1 <br /> i <br />