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c. Tank/Piping Disposal Site: )) <br /> Name ( I n I lL J:�Sa , a C V C Il <br /> Address �?,:�-Oo �/�,•/ 1 ri�i+l*o�.���1- City y, Zip <br /> - <br /> (� <br /> Phone No. ) 44 " -S <br /> - <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YE$CK NO[] <br /> 9a. Describe,in detail,how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> 10. Descrige how the excavation will bq backfilled with sy�itable material upon removal: <br /> f f i v Q Q, l �t3 6 I,�o`L <br /> 11. Handling of excavated soil: <br /> a)What mLrLate]rial will bePSE used to line the tank pit and cover the stockpile? <br /> � >> <br /> b)What ill be the f nee stination of the excav ,� <br /> ed stockp'lev <br /> � � f�,-wAr�p � ��rirll <br /> c)Contaminated Soil Hazardous Waste Hauler: - <br /> Name L4-'R LM Hauler Registration# q <br /> Address 441,b 14Wy q9 1pCity" J Zip <br /> Phone Number 61D 5 ) 9 0 4, 0(p nn ¢ 11 <br /> 12. What is the depth to groundwater?1t1.jp1-0'] r JQP mt,U S' <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well /OO t ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[] NCO( <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 �� n ,1 . � L <br /> Mailing Address J 166 JJw y 99 6� S&LUV A-) <br /> Day-Q[ione Number �(7 �� ^ D(p (p <br /> ignature ��, Date <br /> EH 23 046 (Revised 10/30/12) 5 <br />