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Tank/Eg Disposal Site: <br /> Name a- Lo ',Vj1to I A <br /> �^' ---- <br /> Address t-(�� B� -00-S n City�r�7�niV1f�(P Zip �1N�C� <br /> Phone No.( ) /q,'ogq I -- <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third partyfrom the contractor (REQUIRED)? YESX NO [] <br /> 9a. Describe, in cletail. how the soil and/or water samples) beneath_the tank and piping will be obtained: <br /> h 1 n-k `i 46.Mnl�� <br /> 10. Describe how the excavation will be backfilleq with suitable matrial upon removal 1 <br /> nQC( ��C i �� /,.aj PC,C A I) <br /> --- <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank it and cover the stockpile? <br /> -.e e�lz>�, �r l� 1 , t�� l���j .1 �n P Fir i 11 ►�-� �-UI <br /> b)What will be the final destination of the excavated stockpile? <br /> IA,/\ oLA— 4-h,S -1h�r95C\ �S4 � -Lt�) IGip �1cx�P YVrcltt:6'1�1 <br /> c) Contaminated Soil Hazardous Waste Hauler: <br /> Name D1!-E Hauler Registration# <br /> Address City Zip <br /> Phone Number( ) <br /> 12. What is the depth to groundwater? i Ocr�2! vc1c2S 1\4' C''cy'[Ak'APLPI� An 2� <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 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)? YESV NO[] <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 responsibilityfor the billing by signature and clate below. <br /> ck <br /> Name �C ► N,\,�� ' r4 v\ �Al —_ <br /> Mailing Address AV \3 dv� <br /> Day Phone Number <br /> Titl e to <br /> ...,.r._ . �.., .., . ............ ,rte <br />