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SAN 1 Q A Q U I N Environmental Health Department <br /> - -- COUNTY-- <br /> c. Tank/Piping Disposal Site: /� !� s <br /> Name n /rZ — �A IC. <br /> Address City Zip <br /> Phone No.( 1 <br /> EPA ]DO (if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES NO ( <br /> 9a. Describe, in detail, how the soil and/or wafer sample(s) beneath the tank and piping will be oblained: �/ <br /> ODO' E,v4J,✓rer2rN � �✓ir/ Bot NSR Meek 7D 7AKE nmP/es . Vreas� Sce Civ "n4a'��✓ ',. <br /> yrs �z`.yr✓ .5 , 1` �� G1,4-s <br /> i <br /> 10. Describe how the excavation will be backfilled with suitable material upon removal: <br /> ;Fle f //en WrfN- /e44 L" i<r?r Ones hir 'fieo c41 <br /> 11 . Handling of excavated soil: A/�J�— <br /> a) What material will he used to line the tank pit and cover the stockpile? <br /> b) What will be the final destination of the excavated stockpile? '.. <br /> c) Contaminated Soil Hazardous Waste Hauler: t7 <br /> Name Hauler Registration P <br /> Address City. Zip <br /> Phone Number ( ) <br /> 12. What is the depth to groundwater? " <br /> Describe the source of Information: '.. <br /> 13. Are [here any water wells on this parcel or adjacent properties? YESAJ NO [ j <br /> TYPE OF WELLS DISTANCE TO TANKS(S) v <br /> Public Well Ae/ ft. <br /> Private Well ft. <br /> Iui ation Well ' o't/t'5ft. - <br /> Monitoring Well ft. / n <br /> Other I/41G/ ft, <br /> 14. Will the tank(s) pending closure be replaced Will an aboveground or underground storage tank(s)? YES[ I NOM <br /> 15. Indicate the responsible party to be billed for additional EHD staff lime expended beyond 3 hour minimum <br /> permit payment per lank. if the party designated below is different than the permit applicant, e.g. properly <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Z07:DLJ 571 / 2MWe7KSOn.) <br /> Mailing Address 36 76 Zig 09b� ly" Lgllliter a` t�i9 4ti'9s�D <br /> I <br /> Day Phone Number ( 70 ) 7 G / — / Y O <br /> I <br /> 5 of 10 <br />