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JUAQL (N 10 Envitmental Health Department <br /> COUNTY <br /> c. Tank/ iping Disposal ite: <br /> Name .S >l Qty q <br /> Address �,,JJ p City Zip (J 43/ <br /> Phone No.( � ) [ l /sO <br /> EPA ID#(if transported to a permitted TSD facility) CAI0006 dol/ <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES)f NO[ ] <br /> 9a. Descrpa,in detail,how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> 4AU2 Ago� <br /> 10. Describ ho the excavation will be backfilled with suitable material upon removal: <br /> 7Ai - pew / 0-- 4!Ai? L41mol �l� <br /> 4+oi 415 7`'fS ff <br /> 11. Handling of excavated soil: <br /> a)W at material will bye use o ' the tank pver the,stockpile? �s7IV <br /> b)What will be the final destination of the excavated stockpile? <br /> c)Contaminated Poll Hazardous Waste Hauler: <br /> Name 7, , /yrte �V h '���r--07,-)A / Hauler Registration1# &40 b/o f s. <br /> Address �S !—)A )�1��e city_ Zip <br /> Phone Number( 9� 1 ) y 1b <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES[ ] NO I' <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 ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[ NO[ ] <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 <br /> acknowledge this responsibility for the billing by <br /> signature and date below. <br /> Name LC ?��++,��QrV�G�v?`s ' 1— fN,,pC�A1)15K� f�OQt,.X.nc <br /> Mailing Address '92677 iy • VGW✓�.� ew— Ave— <br /> Day <br /> � <br /> Day Phone Number/� )�c.�_ ctr C4& ✓ ��O �` "� <br /> 5of10 <br />