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0 0 <br />C. Tank/Piping Disposal Site: <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)? 41A <br />YES [ J NO [ J <br />9a. Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br />1 <br />10. Describe how the excavation will be backfilled with suitable material upon removal: <br />11. Handling of excavated soil: <br />a) What material will be used Jto Ij 2Ae tank pit and cover the stockpile? <br />b) What will be the final destinattiwe excavated stockpile? <br />c) Contaminated Soil Hazardous Waste Hauler. <br />Name , I }A Hauler Registration # <br />Phone Number <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 [I NO[] <br />LLS <br />DISTANCE TO TANKS(S) <br />ft. <br />;PrivateWell <br />R <br />ft.ll <br />ft <br />ft <br />2017 <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NOi <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 parry designated below is different than the permit applicant, e.g. property <br />owner, the parry must acknowledge this responsibility for the billing by signature and date below. <br />Name YF,(, F2GI(�J1 i ArtA: ML Q,oPE/� BY 62 L6 <br />Mailing d 's 15?s E. PEScpa6fLa AVi$.t T"t>f C.54E3Orl <br />Day Pho a mber ( R 13 ) If Lf _ ; fic.t N <br />Signature 2 -29 -Pt <br />Title Date <br />EH 23 046 (Revised 726/2016) 5 <br />