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I, <br />Gr%/GG r3>e_r t,7 /Sty©So;` X1&.1 P y999 5 . e4STi•J i?M tJ <br />� 1VAN7je,-V c.q. <br />C. Tank/Piping Disposal Site: r'irt niF (za9) `JSf2. -'/-Z 15; Sr <br />5/E G i'f'/.tle:-iName {5611AI//ZZ2< 57K,64 120dUC/3_ <br />Address_/.Z oOB /=oL5o,-n /31ai3. city �a/z zip 5 L <br />Phone No.( 9/6 ) 9,* 5- - zj '/o <br />EPA ID# (if transported to a permitted TSD facility) <br />9. Is the sampling fine an independent third party from the contractor (REQUIRED)? YESg NO[] <br />9a. Describe, in detail, how the soil and/or water sample(s) beneath the tank and Dioina will be obtained: <br />1JkESE.v7 QCe✓/64 14f�4/L aFx-vZj_� 7"9.CV-,V <br />10. Descry be how the excavation will b�backfilled with suitable material upon removal: <br />11. Handling of excavated soil: <br />a) What material will be used to line the tank pit and cover the stockpile? . <br />6/t''Z 13d'I PJ "'f Si/C <br />will be the final destination of the excavated stockpile? /r .S 70e,< IS 60.4 <br />c) Contaminated Soil Hazardous Waste Hauler. <br />Name 121«1ftd 45W1%t0,'JMf-v74Z Hauler Registration# <br />Address PO 30 Sl % g city �Y/20✓1) t✓9 zip "%S �/¢ <br />Phone Number ( 9.2 S ) e S <br />12. What is the depth to groundwater? /25W/ <br />Describe the source of information: // <br />13. Are there any water wells on. this parcel or adjacent properties? YES [I NOK <br />14. <br />15. <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />R. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitorinq Well <br />ft. <br />Other <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? <br />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 <br />Mailinc <br />YES[ ] NOX <br />Day Phdne Number <br />$Ig re Title Date <br />1 <br />EH 23 046 (Revised 10/30/1) 5 <br />/LL /A/OIS <br />God �/ <br />