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c Tank/Piping Disposal Site <br />RECEIVED <br />NOV 222016 <br />Name Modesto Junk Company. Inc. „ „ ENVIRnI`IMENTAL HEALTH <br />Address 1425 9th Street City Modesto zip 953;)F-PARTMENT <br />Phone No.( 209 ) 522-1435 <br />EPA ID# (if transported to a permitted TSD facility) N/A <br />9 Is the sampling firm an independent third party from the contractor (REQUIRED)? YES NO ( ] <br />9a Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br />Soil sample will be obtained utilizing slide -hammer tool with 2" x 6" brass or stainless steel tube. Sample will be <br />logged on chain -of -custody then placed in cooler chest with blue ice for transporting to Cal Ag Lab via ECG (see p 3). <br />10. Describe how the excavation will be backfilled with suitable material upon removal. <br />UST displacement will be replaced with self -compacting clean material then balance of excavation filled with native <br />soil to sub -grade allowing for placement of sod to match existing lawn in front -yard of residence. <br />11 Handling of excavated soil, <br />a) What material will be used to line the tank pit and cover the stockpile? <br />20 -mil black plastic sheeting <br />b) What will be the final destination of the excavated stockpile? <br />If excavated stockoiled material is free of contamination same will remain on-site. <br />12 <br />13 <br />14. <br />15. <br />c) Contaminated Soil Hazardous Waste Hauler <br />Name Dillard Environmental Services Hauler Registration # 1715 <br />Address 3120 Camino Diablo Road (P.O Box 579) City_ Byron_ _ Zip 94514 <br />Phone Number( 925 ) 634-6550 <br />What is the depth to groundwater? (+/-) 90 feet <br />Describe the source of information: Property owner <br />Are there any water wells on this parcel or adjacent properties? YES (� NO[] <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft <br />Private Well <br />(+/-)100 ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? <br />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 Same as 7fb} above <br />Mailing Address <br />Day Phone Number (_ <br />ignature <br />EH 23 046 (Revised 7126/2016) <br />Title <br />11 /71201 6 <br />Date <br />YES[ ] NO[J <br />