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RECEIVED <br /> SEP 10 2019 <br /> ENVIRONMENTAL HEALTH <br /> JPERMIIT AERVIC :4osal Site: <br /> Name / R � / �� l ` �Z � J !/ � %S <br /> Address 6 �(� � � Ro Ciq /afAteo "2%p <br /> Phone No. ���pp <br /> EPA ID# (if transported to a permitted TSD facility) a� hf 00 Lw gl <br /> 9. Is the sampling firm an independent third parry from the contractor (REQUIRED)? YES [x NO [ ] <br /> 9a. Describe, in detachw the , oil and/or water sample(s) beneath thtank, and piping will be obtained: <br /> C 4bC 7 - <br /> 10. Describe how the excavation will be„Wackfi d with suitable material upon remo a1. <br /> � £� f cow 7 .J .✓ e <br /> 11 _ Handling of excavated soil: e0#10 t Wi <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? 7C/ 4 <br /> c) Contaminated Soil Hazardous Waste Hauler: <br /> Name Hauler 1�i' /1 1���1t' a f�/��� HaHauler Registration # � ���� <br /> Address P box S /^7 V/ City / %b' Zip C l y <br /> Phone Number ( <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: /` ! S C �t kA S ZV 7 Z �7 _ 3 /L v <br /> 13. Are there any water wells on this parcel or adjacent properties? YES(JNO [ ) <br /> TYPE OF WELLS DISTANCE TO TANKS (S) <br /> Public Well ft. <br /> i <br /> Private Well J Q ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> P Other ft. <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 y <br /> permit payment per tank. If the party designated below is different than the ermj applic nt e. g . property <br /> owner, the party mustacknowledgethis respo`nssiibility ffor tthe�billing by signatur a d 1w <br /> Name �-L , l✓1 G < / ! / C <br /> Mailing Address 47— 11'Z <br /> 1 <br /> Day Phone Number � © " 47 <br /> a <br />