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1 c. Tank/Piping Disposal F"'-: <br /> Name_ <br /> Address / , �J P l S�!,��j� ���city <br /> C2j<I�C761,f Zips <br /> Phone No.(W� Cf �5 14O l,151 <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YE� NO[] <br /> 9a. Describe, in detail, how the s it and/ r water sample(s)beneath the tank and piping will be obtained: <br /> ?� c o,6 f3ce ,c: / �-�y <br /> �/-T £ 41G1CF 7 02 1!t 4W Lf �Z <br /> 10. Describe how the exca ation will be b c�l�filled wjth suita�a material upon removal:j <br /> K F/C 4/e Thi S£Gr oa.-7/ J',� <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit and co_v�e tt sto/ile? <br /> L C/� /0�"y %/� <br /> b What will be the final destination of the ex vated stockpi /�S'i-� r'iLf �s �' "Tf"� ✓-9i�%� <br /> ir , o j--vr?c4)4, J i _ Clf fV <br /> ctyContammat� �/�2/3vrZS�.►� <br /> of azardous Waste Hauler. <br /> 1 IL/ ',r <br /> Name 'l/ �///ld �' )Hauler Registration #�_7 <br /> Address �(�(�� 5 I /Z01City `� yiW/J Zip 2 fzt <br /> Phone Number(_ ) 6�S *-q"z 92 S C —Of-7 <br /> r _ <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: Iz <br /> 13. Are there any water wells on this pargel or adjacent properties? YES [] NO <br /> i <br /> TYPE O WELLS DISTANCE TO TANKS(S) <br /> LJ <br /> Public ell ft. <br /> MAR 2 1 2016 <br /> Priv to Well ft. <br /> I ation Well ft. ENVIHUNMENTAL <br /> onitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s) pen ing closure be replaced with an aboveground or underground storage tank(s)? YES[] N <br /> /\ <br /> 15: Indizate the res nsible party to be billed for additional EHL) staff time expended beyond 3 hour minimum <br /> permit payme 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 /7 ✓���./ c- 7/ <br /> Mailing Address uZ 1*S7�, 4,:f 7,<— 2-0 2-- <br /> 10 <br /> Day e Number� Q d" <br /> Signature Title Date <br />