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SAN ,, JOAO U IN R E G �F"', E DEnvironmental Health Department <br /> --,--COUNTY____._ 00 0 1018 <br /> ENVIRONMENTAL HEALTH <br /> C. Tank/ ipirxl D* set Site: D PARTMENT <br /> NameSo 4; ma-0i <br /> Address hf cit t.,,,VZYp <br /> Phone No.(_ 36—6 vy-V'k <br /> EPA ID#(if transported to a permitted TSD facility)_CATVOOK w 1 <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES Y NO[ I <br /> 9a. Des%Lln detail, <br /> =ndlor water sample(s)beneath the tank and piping will be obtained: <br /> Aw <br /> 10. Desuhc*the excavation will be backfilled with suitable material upon rem at: <br /> ,W <br /> 11. Handling of excavated soil: <br /> a) material wit UsWeo the tank Avert e tockaft7 C <br /> WYO <br /> Wat, —/d.s/ <br /> 77--- <br /> b) at fl e f al destination of I e avated toc Ile <br /> • <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> Name Hauler Registration# <br /> Addresse city .. Zip <br /> 44 <br /> I'M 11 <br /> Phone Number( )- VLo— 12:!�! <br /> 12. What is the depth to groundwater? AIIA <br /> Describe the source of information:---O-�--*" <br /> 13. Are there any water wells on this parcel or adjacent properties? YES I j NOV' <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well <br /> Private Well ft, <br /> lrr' atlon Well ft. <br /> Monitoring Well ft, <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES X NO[ I <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 LC &g4-_1 ' CIO ®Au)( <br /> J'% 16141 <br /> Mailing Address 390 Uol")nf-= <br /> 30 cp-e- <br /> Day Phone Numbercs"----, qLN-0 <br /> 5 of 10 <br />