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x � IJ <br />c. Tank/Piping Disposal Site: <br />c fh"A,anrnental H aKh Dc pari "'tp, R- <br />Address/Z2- I 54Z E&et city�aS1ZJ Q&, zip <br />Phone No. )6 3 <br />EPA ID# (if transported to a permitted TSD facility). 41 <br />9, Is the sampling firm an independent third party from the contractor (REQUIRED)? YES NO[ ] <br />9a. Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obt�pol _ y, <br />Handling • •soil: <br />a) What material will be . to line th5tank pit and cover the stockpile? <br />w <br />b) What will be thelinW destination of Ithe <br />♦ �. - s <br />•taminated Soil Hazardous <br />Phone Number <br />2, What is the depth to groundwater? , " L _ �" <br />Describe• of • • <br />13. Are there any water wells on this parcel or adjacent properties? <br />14. Will the tanks) pending closure be replaced with an aboveground or underground storage tank(s)? <br />15. <br />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 respons/ibility for thee+ billing by signature and date below. <br />Name / Z J?�' ® 1 b '400 <br />Mailinc <br />Day Phone Number <br />5of10 <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft, <br />Monitoring Well <br />ft, <br />Other <br />ft. <br />14. Will the tanks) pending closure be replaced with an aboveground or underground storage tank(s)? <br />15. <br />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 respons/ibility for thee+ billing by signature and date below. <br />Name / Z J?�' ® 1 b '400 <br />Mailinc <br />Day Phone Number <br />5of10 <br />