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C. Tank/Piping Disposal Site: <br /> Name .P,aXbc/C 5/a,¢VirCSyAsco ROAD I.A^t04w <br /> Address `/00//t/. VASco K_0 . CRY C'VAFAM017E Zip 9r15�/ <br /> Phone No.( 5/0 ) 2(e-Z _ I6(v, <br /> EPA ID#(if transported to a permitted TSD facility) <br /> 9. Is the sampling firm an independent third party from the contractor (REQUIRED)? YES NO j j <br /> 9a. Describe,in detail,how the soil and/or water sample(s)beneath the tank and piping will be obtained: <br /> Sorc sAMPICa Wru- Se cocWcM,0 01xDW AAC&MOe aucEerAA/Dmt.-PARS i,.,P/So3/ <br /> /ZO etOr/,025 . re0_OUA/3W MC Z_SAMPLES WS&W exCA4A+r0 W ICL da COC(ecl&c) W19y <br /> {SA r✓t'FL P (4A,6-014/70 VOA V,ACS . <br /> 10. Describe how the excavation will be backfilled with suitable material upon removal: <br /> PoyowlA(4 (LE/Y/oyAt_ or ^ZZ usr's /6CCAv*rw wai i3a FrUe-o (./7}/So/TAZ(E MA,-M111Af- <br /> 1b ALCOtU Fon- MJEgUAr&_ GOMAACT/J <br /> 11. Handling of excavated soil: <br /> a)What material will be used to line the tank ph and cover the stockpile? <br /> vrs�uE��/ PCAsnc <br /> b)What will be the final destination of the excavated stockpile? <br /> rb IIE De7�it.r-r,n/h1] <br /> c)Contaminated Soil Hazardous Waste Hauler: <br /> GA/L_ 000/ro5i7'f 3AB � O <br /> Name /NT9/n/5,L T(zA&,% PcerArloa Hauler Registration# ArSG*1,17A171 pAtV CA 1 <br /> Address 2225 c./�1s.L�cnlc/C2 G✓/`'J `/00CRY _5arvrr>'aoak Zip <br /> Phone Number 70 ) 57 — 'D5;6 o <br /> 12. What is the depth to groundwater? Gs M JIr/�ieINr6J�/V/.#lWi1�//l/JJIC.� l�/W✓�sNA(u�'�, <br /> Describe the source of information: P~I Br At"" !/VV/AQVMlWr4C_,��/w/C <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NOty <br /> TYPE OF WELLS DISTANCE TO TANKS(S) / <br /> Public Well R. <br /> Private Well R. <br /> Irrigation Well R. <br /> Monitoring Well R. <br /> Other R. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or ndergroun storage tank(s)? YES )[1 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 acknowledge this responsibility for the billing by signature and date below. <br /> Name A#Mkb C71V,&ba&_ <br /> Melling Address ,290r(r_ bAAfO CtlA/ (z/J . CAA(f'OA/ (OdA/flzy r,4. gr3$7 <br /> Day Phorte u tber / ) a s o—9 Soo <br /> poJ�r��s'rAnlaaE,� a x3 / <br /> Signature Title Date <br /> EH 23 046 (Revised 8/1/11) 5 <br />