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S A N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> C. Tan kJPiping Disposal Site: <br /> NIA <br /> Name <br /> Address Cily Zip <br /> Phone No.( ] <br /> EPA ID#(i f ire nspeed to a permitted TSD facilily) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? NIA YES( NO[ ] <br /> 9a. Describe,in detail,haw the soil andlor water samples)beneath the tank and piping will be obtained: <br /> 10. ❑escribe how the excavation will be backflled with suitable material upon removal: N/A <br /> 11. Handling of excavated sail: NIA <br /> a)What material will be used to Ilne the tank pit and cover the stockpile? <br /> b)What will be the line!destination of the excava led stockpile? <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name Hauler Registration# <br /> Address City. Zip <br /> Phone Number�_ } <br /> 12. What is the depth I groundwater? <br /> Describe the source of information; <br /> i3. Are there any water wells on this parcel or ad]acent properties? YES[ ] NO[ ] <br /> [ TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well fl. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft, <br /> Other ft. <br /> 14. Wit the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO)() <br /> 1s, Indicate the responsible party to be billed for additional EHD staff time expended beyond 3 hour minimum <br /> permlt 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 dale below, <br /> Name Bagley Enterprises <br /> Mailing Address, 2370 Mi3ggib.Cir##4 Lod}CA 95240 <br /> Day Phone Number 1 20$.367.41300 <br /> 5of10 <br />