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<br /> <br /> <br />5 of 10 <br /> <br />Environmental Health Department <br />c. Tank/Piping Disposal Site: <br /> <br />Name_________________________________________________________________________________ <br /> <br />Address________________________________________ City_________________ Zip_______________ <br /> <br />Phone No.(__________)__________________________________________________________________ <br /> <br />EPA ID# (if transported to a permitted TSD facility)______________________________________________ <br /> <br />9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES [ ] NO [ ] <br /> <br />9a. Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br />_____________________________________________________________________________________________ <br />_____________________________________________________________________________________________ <br /> <br />10. Describe how the excavation will be backfilled with suitable material upon removal: <br />_____________________________________________________________________________________________ <br />_____________________________________________________________________________________________ <br /> <br />11. Handling of excavated soil: <br /> <br />a) What material will be used to line the tank pit and cover the stockpile? <br />_____________________________________________________________________________________________ <br /> <br />b) What will be the final destination of the excavated stockpile? <br />_____________________________________________________________________________________________ <br /> <br />c) Contaminated Soil Hazardous Waste Hauler: <br /> <br />Name__________________________________________________ Hauler Registration #____________________ <br /> <br />Address___________________________________________ City______________________ Zip_______________ <br /> <br />Phone Number (__________)______________________________________________________________________ <br /> <br />12. What is the depth to groundwater? __________________________________________________________________ <br /> Describe the source of information: <br /> <br />13. Are there any water wells on this parcel or adjacent properties? YES [ ] NO [ ] <br /> <br /> <br />TYPE OF WELLS <br /> <br />DISTANCE TO TANKS(S) <br /> <br />Public Well ft. <br /> <br />Private Well ft. <br /> <br />Irrigation Well ft. <br /> <br />Monitoring Well ft. <br /> <br />Other ft. <br /> <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[ ] <br /> <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 /> <br />Name _______________________________________________________________________________ <br /> <br />Mailing Address _______________________________________________________________________ <br /> <br />Day Phone Number (__________)_________________________________________________________ <br />