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c. Tank/W�W 4:Dlsoosal Sits: <br /> Name <br /> Aclelress_Lj � S CI#y�I t)��hi '�aEe p <br /> EPA ID#'(If.#i'anslimrted to:q liarmlttadTSD'faclllt' <br /> 9., fs.the.sampling flan-on Jndependent',thlrcl pai'tytl'atn .,can actor (REQUIRED)? YEP)d NO[,I. <br /> Via. Descitbe,In cl #aq;110w1he sell and orwater:sampla:(s)beneatti�the tan a, nd. <br /> „plpiny.wlll lie-DI .. et: <br /> 10. Describe how:thePszcavatlon will be:;bacid1le. wtlisultabla:mat rial::upon removal: <br /> I.1. Harrclliti :gfi ex+lawatecl sail: <br /> l <br /> I. aj what material if be user to line ti)a.tank pit ancl,cDvartq#stockplks7 <br /> j b)What will be"the finaF destlnatlori of:the excavated stockpileIf <br /> �: <br /> aA <br /> F w)Cnritariilnateslpl[t►azardous VilasteFia0let: <br /> Mania Den &P-44—,. �d Gras 6` G1. Haul er:Rajistratinn�# <br /> i. bP5 �:�- city tfl�r� soC yip q7 f'Z- <br /> r Address_ <br /> -Phone Number(900 IR V" I L <br /> 12. Vtfhat9s.the depth:to groundwater'? s, <br /> 3. <br /> Describe aliesbures of irifdrniaitan: I' <br /> I& Are there anywater webs nn thts pareel-mr-adjacent'properdes? -YES [.] NO `. <br /> E <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Pu�I1cw1`,fell � <br /> Private Well • <br /> lrr atlon Well I <br /> r' <br /> , <br /> Monitorin W611 �• <br /> Other` <br /> l s <br /> 14. WI(I the tanfc(s}peh>aing.plosura.he ralslaced with an a6oueyraund or unclergroun_d starage tank(s)?' YE. NO[.] t <br /> 16. Igglcate the rasponsilile party-to bed.bllled for addltional..EHD staff time.eXpended beyond 3 hour.minimum <br /> 'i permit payment.per tank. 'if lie paity-.dasignatedbelow is dlfferpht than the permit applicant, a g..;property <br /> mwner,the party mustacknowisdgelthis responslliillty,forthe bliling bysi.gnature anti date balow. <br /> VVI <br /> Narma <br /> kAJ <br /> d <br /> t <br /> Malling Address <br /> Day Phone Number <br /> ,f\ �Yts <br /> .. -i•Ifl.$• � q <br />