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j <br /> C. Tank/Piping Disposal Site: NA— VAV + 0111 ded ! Ba (Of,- f ow"`t' <br /> Name <br /> Address City Zip <br /> Phone No.( ) <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? <br /> YES;K NO[) <br /> i <br /> 9a. Describe,in detail,how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> 5GE AnA U1 <br /> 10. Describe how the excavation will be backflledwith itabl material uon removal: <br /> camwa o `tl be- 4eC� «riC P �t t 4-,dr ►se�r <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank pit and cover the stockpile? <br /> b)What will be the final destination of the excavated stockpile? <br /> CLASS Zt LAar-(y-- P4WAA-* Ftt.L I& ,rot e-A <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Namehit' e- Hauler Registration# <br /> Address 31c) DPS C� 7++` f o-7City ' <br /> P $°V: zip `3 Sof 4 7- <br /> Phone Number( 13 go 1 8 3 3 r t K 7 <br /> 12. What is the depth to groundwater? --7 r <br /> Describe the source of information: <br /> ou-si p?d1gf� lertr <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO[] <br /> i <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. A <br /> Private Well T-®0 ft. <br /> i <br /> Irrigation Well ft. WA <br /> i <br /> Monitoring Well `� [ °U ft. <br /> Other ft. AdA <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 A S0641we-kTVIC. <br /> Mailing Address 2s�� h(td�06Ntb! �qrk Dave �sv, Saeravnt40 <br /> ,C_A <br /> qq <br /> Day P one Number( R t ) i��' 376 l�• (` I <br /> 6 JAS Z-0 Z- <br /> Signa T e Date <br /> EH 23 046 (Revised 8/1/11) 5 <br />