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C. Tank/Piping Disposal Site: <br /> Name <br /> Address 1'- - City Zip CtNJ <br /> S�3 <br /> Phone No.( 2M _)_(12Gt -q31 V <br /> EPA ID#(if transported to a permitted TSD facility) l.'N1N <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES[ NO[] <br /> 9a. D cribQ in detail, ho the soil and/o water sampl )beneath the to k and p' ing wily)be o tained: 1' <br /> lip `1 Pi`� .7 �1tr7i'�V/� cirn� Uy�,t7 r.- LL 4C L�i t�.i�LSC TN LX <br /> , re u u . . n <br /> 10. D tribe how the excavation will be back Ile with s itabl m tef I up n moval: j <br /> iA4 I A 1 1 I <br /> t �lt{ As, x.• <br /> 11. Handling of excavated soil: <br /> a)What mat ri�{vill be used t e the t nk p' and cover tk�e stockpile? <br /> �e2 �'2�r<t� rte �¢�It "rr3ijiV " <br /> bl What will be thelfinql destination of the excavated stockpile? <br /> TIS 10 Cl to T&kA lc--- I? telt V�j&LaVJ iqi i S <br /> c)Contaminated Soil Hazardous Waste Hauler: /ZJ 7a b <br /> Name C) V";j_is \1r<:AAS t15 ,.� Hauler Registration# <br /> Address gl l_y P(.7�,�iz �L< C-X- �u 112 city (?uF�"�Snlr Zip Q C y�f'L <br /> Phone Number( SLY) g3 'd — 114-1`1 <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NO'?j <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. NOV" <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[] <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 rye eV 1A 1A ert kt <br /> - <br /> Mailing Address 2yS tv• �..F. 11%, \` YNAta-�...�Ls„yi a l 3 Ll <br /> Day Phone Number O ) 4c tCi IA^ <br /> GI� J�� 'c_/ YV\sr ' ZZ 1 <br /> Signature Title T Date <br /> EH 23 046 (Revised 07/22/10) 5 <br />