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C, Tank/Piping Disposal Site: <br /> Name <br /> Address / 000 ^� SfJ 1,. City �� Zips <br /> Phone No. (d <br /> EPA ID# (if transported to a permitted TSD facility) <br /> 9 . Is the sampling firm an independent third party from the contractor (REQUIRED )? YEP( NO [ ] <br /> 9a. Describe, in detail , how the soil and/or water ple(s) beneath the tank and piping will b,� obtained : ,7d®iYA� S' <br /> . vX40 <br /> t i ' <br /> 10 . Describe how the excavation will be backfilled with suitable material upon removal : <br /> ! rd 4dd4oQ0Z 02- 3/dl �/ c .Zdc//X/J iL�G� l S�GFeyeyl� i �f�, <br /> 11 . Handling of excavated soil : S`Fl jC � , G/9G �i� ® �Jj ✓ IGC %J� G�� ! �G � 5 <br /> a ) What material will be used to line the tank pi and covert the stockpile? <br /> i��4 <br /> 3 <br /> b) What will be the final destination of the xcavated stock Ile? % Gr;/ 40agoO <br /> c) Contaminated Soil Hazardous Waste Hauler. <br /> Name /)/ ,/L/" (2I�/yy/,✓ri�zG!�(� ifi//� Hauler Registration # � / <br /> Address_e ( rX ✓ 13Y <br /> /&A) City 3 zioeO ZitP �A <br /> Phone Number ( (y S � � a � / � `� ® , <br /> 12. What is the depth to groundwater? <br /> Describe the source of information : Ke i 7/ <br /> 13 . Are there any water wells on this parcel or adjacent properties? YES [!� NO [ ] <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[ �9t; <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 permit applicant, e .g . property <br /> owner, the party must acknowledge this responsibility for the b' ling by signature and date below. f <br /> Name <br /> Mailing Address { <br /> Day Phone Number G- Q7 ) 7 7 / <br />