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C. Tank/Piping Disposal Site: <br /> Name NA - No piping being removed. <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 (REQUIRED)? YES N NO[] <br /> 9a. Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br /> See attached work plan. <br /> 10. Describe how the excavation will be backfilled with suitable material uon removal: <br /> v� <br /> An excavations will be backfilled with clean fill materiae Borings will be backfilled according to <br /> wK pta . <br /> 11. Handling of excavated soil: <br /> a What material will be used to line the tank pit and cover the stockpile? <br /> o stockpile anticipate. If a small volume of soil is generated it will be containerized in DOT drums. <br /> b What will be the final destination of the excavated stockpile? <br /> �propriate landfill facility, if necessary. <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name Hauler Registration# <br /> Address City Zip <br /> Phone Number( ) <br /> 12. What is the depth to groundwater? 45 feet; data from Geotracker sites near property. <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [A NO [] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well 2000 ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well 1500 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 St. Joseph's Medical Center-Attention Mr. John Stagg <br /> Mailing Address 1909 Cemetery Lane, Stockton, CA 95204 <br /> Day Phone Numbe 209 461-6818 <br /> Assistant Chief Engineer <br /> Signatur Title Date <br /> EH 23 046 (Revised 8/1/11) 5 <br />