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Tank/Piping Disposal Site: <br />I I`V LI V LZLd <br />MAR 16 2015 <br />ENVIRONMENTAL <br />' / �1 l4l=VTFJ r`C0A0TA/Tu1T <br />Name�WB)t/L f' %A)6 !J <br />Address 7 �2/ s. 4W;7% !� 4o City 101' AJ7c?C4 Zip 95-7 <br />- (--- -'---- <br />Phone <br />EPA ID# (if transported to a permitted TSD <br />9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES,4< NO [ ] <br />9a. <br />10. <br />11. <br />12, <br />13. <br />Handling of excavated soil: <br />a) What material will be used to line thg tank it and cover the stockpile? <br />b) What will pe the final destination of the excavated stockpile? /N STG/l JiG� /S ca.�iysys�n.��T�'r) <br />UEc,6O✓G3iRSFf1 e'Ae�) Tiff/Fdr<S or to ✓ia� ✓n y LJiiL i) itTr7r i7fi zJiLoSylS,1£ <br />c) Contaminated Soil Hazardous Waste Hauler: <br />Name 1)&C///L,G) Hauler Registration # 1 Z S <br />n� <br />Address PD j,Ge/5-;7 y���J/2Q�� City ByleeA Zip --y <br />Phone Number( 7�.� ) l43 7 -/���J x�/�7,�$�' <br />What is the depth to groundwater? 7 /IIJ,PD <br />Describe the source of information: ' <br />Are there any water wells on this parcel or adjacent properties? YES NO [ ] <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />MonitoCinq Well <br />Z00 ft. <br />Other <br />ft. <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NCX\ <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 or the billing by signature and date below. <br />Name NGS /U Cg vkqo <br />Mailing Address <br />Day Phone Number C- <br />Sig a u Title Date <br />EH 23 046 (Revised 10/30/12) 5 <br />