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SAN J Q A QU I N Environmental Health Department <br /> --_. - COUNTY . -- _ . <br /> C , Tank/Piping Disposal Site : <br /> Name <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 (REQ D) ? YES [ ] NO [ J <br /> 9a . Describe , in detail , how the soil and/or water sample (s) beneath the t and piping will be obtained : <br /> 10. Describe how the excavation will be ba fill d with suitable aterial upon removal: <br /> 11 . Handling of excavated soil: <br /> a) What material will be used to line the tan it over the stockpile? <br /> b) What will be the final destination o e excavated stockpile? <br /> c) Contaminated Soil Hazardo Waste Hauler: <br /> Name Hauler Registration # <br /> Address City Zip <br /> Phone Number ) <br /> 12. What is the d th to groundwater? <br /> Describe ih source of information : <br /> 13 . Are the any water wells on this parcel or adjacent properties ? YES [ ] NO [ ] <br /> tat <br /> TYPE OF WELLS DISTANCE TO TANKS ( $) <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 Spanos Corp <br /> Mailing Address 10100 Trinity Park West 5th Floor Stockton , CA 95219 <br /> atat <br /> Day Phone Number ( 209 ) 478-7954 <br /> 5of10 <br />