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c. Tank/fig Disposal Site: <br /> Name V X25 LD ',1�(l y <br /> Address 11co) N- �Oc& 1� W City LiotrftjW Zip MSCI <br /> Phone No.{ <br /> EPA ID#(If transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third partyfi-om the contractor (REQUIRED)? Sx NO [] <br /> 9a. Describe, in detail. how the soil and/or water sample(s) beneath the tank and piping will b obtained: <br /> h <br /> 10. Describe how the excavation will be backfille with suitable mat tial upon remova. <br /> flan � <br /> f xr <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank nit and cover the stockpile <br /> ^t e C►vc k��le r Lt1 hQ eu ( � a�n tt�r�r cu 11 b-t '—LALnA <br /> b)What will be the final destination of the excavated stockpile'P <br /> �o:,e��►�Ne %fxkr�u 1 <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name fJDn-� Hauler Registration# <br /> Address f' City Zip <br /> v <br /> Phone Number( ) ✓ <br /> 12. What is the depth to groundwater? S W4- A ej -\fn <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or accent properties? YES [] NO <br /> TYPE OF WEL DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private We ft. <br /> Irri atio ell ft. <br /> Monit rin Well ft. <br /> Ot r ft. <br /> 14. Will the tank(s)pending IOSUre be replaced with an aboveground or underground storage tank(s)? YESV NO[] <br /> 15. Indicate the responsi le party to be billed for additional EHD staff time expended beyond 3 hour minimum <br /> permit payment per, ank. 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 /> Mailing Address _ <br /> Day Phone Number <br /> Signature Title Date <br />