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SANJ U t1 Environmental Health Department <br /> C C) IJ V-. I T Y <br /> c. Tank/Piping Disposal Site: -y <br /> Namel�fi +�Ii� y�/ .'_ "/'Lnj�Gl'<i!✓ / <br /> Address l4 Z 1 15dJ71!l /!' CC�Np�rZ Clty7r U,OG Zip <br /> Phone No.( 2p F 6 ICJ f " L 3 7,,8,"`J <br /> EPA ID# (if transported to a permitted TSD facility) 4 �� <br /> 90 is the sampling firm an independent third party from the contractor (REQUIRED)? YES k NO [ ] <br /> 9a. Describe, in detail, how the soil and/or w er sample(s) beneath the tank and piping will be obta' ed* <br /> Jae 50 <br /> dew <br /> 10. as be ho3Ethe excavgtion wi 1 be b kfiiled with s itable material upon removal: <br /> 11 . Handling of excavated soil: <br /> a) What material willa used to line th5tank pit ani,jc cover the stockpile? <br /> zGG ll.a� ,f 2 ;,e 4f 2 / G <br /> b) What will be the n destination of e e vated stoc IV ? <br /> <r C L �'� , / ea BX r'�E;7�lt �� o iH� � �Nvi C�EA� <br /> �>'ontaminated 3 HCaz ousOH 99 441 <br /> Name fL� � 0 FA) VW�W�/�� k Hauler Registration # <br /> 3/ <br /> AddressL.y C#91/% � DCA/B-40 121), City, 43 ygat Zip <br /> Phone Number ( ° � ?5 ) 4C� .J J PNOI ' �� _ <br /> 12. What is the depth to groundwater? 0 . W- ZWe.1 <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[ ] 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 billing by signature and date below. <br /> Name D P /too & <br /> Mailing Address 4. l le <br /> Day Phone Number C -,1 � F,t <br /> 5of10 <br />