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REGLiVEL <br /> C. Tank/Piping Disposal)Site: / MAR Q 2 2016 <br /> Name _S 77-1 �� <br /> � TA L <br /> Address Z/k 0 C)0 � JKS c"'-'I /ed, �/Cityr-29'c dvV'f Zip ' �u IIACV " <br /> Phone No. 2 (� elC,� /- / p� <br /> EPA ID#(if transported to a permitted TSD facility) ��/' I)©�2 8yo6 <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YE> NO[] <br /> 9a. Describe, in detail, how the spit and/ r water sample(s)beneath the tank and piping will be obtained: <br /> 10. Describe how the excavation will be b kfilled with suitable material upon removal: <br /> K F/C �7 Clz 7, '�S��r cam �c7✓� " ,2 c c�>✓�� 2G/� v'��l' <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank t and cove t stockpile? <br /> b What will be the final destination of the exc vated stockpile? /— s'��%CK !'��� is Co.v��fmi•,iq if�� <br /> £c /</Gs3 tolIe-' i3£ 8-/Sf/� el► 7e'j o,,.T�•r/,,v /�T <br /> c)Contaminated Soil Hazardous Waste Hauler. <br /> Name /�%�� << Hauler Registration# � 7� <br /> Address V ���� /2U� City l yiWs�J Zip 2S <br /> Phone Number( (' 3 �S fJ j=fA}L CJZ S 3 ��O� 7 <br /> 12. What is the depth to groundwater? 6c) <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 T- ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[] N <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 responsibility for the billing by signature and date below. <br /> Name i7_ t/�Je2, J Sc 0/ <br /> Mailing Address3 RFs���tcl� G �]�/� S!2,'7-'5E 2-0 Z <br /> D�Rh <br /> eae Number( � ' Q — d <br /> X2 /,Al.-I <br /> Si nature Title Date <br /> EH 23 046 (Revised 12/10/2 5 <br />