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SA N J O A Q U I N Fnvironnle>nfal Health Dep„rtinen't <br /> Costco Fuel Facility #1091 / Our Job No. 14573.11 <br /> c. Tank/Piping Disposal Site: <br /> Name_ 11/41 ROAP5 1-A `-'1>F;ZLL-- <br /> Address Z� i4/1y /�V.AD City �lAeAV=W-1 Zip 9 56 87 <br /> Phone No.( 70 7 ) to l J, .,l 7) ,? <br /> EPA ID#(if transported to a permitted TSD facility) ILIM <br /> 9, Is the sampling firm an independent third party from the contractor (REQUIRED)? YES [X NO [ ] <br /> Sampling Company Name Kleinfelder <br /> Address 25 Metro Drive, Suite 110 city San Jose, CA Zip 95110 <br /> 9a• Describe, in detail, how the soil and/or water sample(s) beneath the tank and piping will be obtained: <br /> Soil samples will be collected in native soil beneath the UST and product lines as <br /> needed using decontaminated hand anger Gamplinn o t� hrnl l -theme <br /> excavator bucket. <br /> 10. Describe how the excavation will be backfilled with suitable material upon removal: <br /> UST tank hole to be backfilled vnth skid steer units loaders and compacted in Its per engineers specifications using class II base or approved aggregate <br /> 11. Handling of excavated soil: <br /> a) vvlldl II1dwildi wlli bC uSeU lu Illld 0lu Cdim pit d11U UuVCI tllu dtVU6pitC? <br /> Geo fabric/Geo membrane per engineers specifications. <br /> I VVIItlt Vl•III UC 111C IIIIdI VCJLIIIGIIUII VI IIIC C)ll:gV CU A'lV1.11�1IIC' �r `1 <br /> 403 West Woodbridge Rd,Woodbridge,CA 95242 p0}rLt—A `I Al �,01\6C A : U6'15 Pof I 'D UVA5 Li -)tm- n C r$�e CA <br /> - c'I Contaminated Soil Hazardous Waste Hauler: a451$5 <br /> Name_ 1 -b akell o - it atnSrr�atl o n Hauler Registration i -WA- 10300 <br /> Address_ Z HOL4 Amore tko 54 city 54 CA10on - zip a5Z1_0 <br /> EPA ID#: (&looU tl y1 81 <br /> 12. What is the depth to grou water', sid f�r IL <br /> Source of information: [ It 2 t yy � � � f1SCrV1A4eb� � 1 u 't;u G ro'V jay' ' b`� ); <br /> '13. Are there any water wells on this parcel or adjacent properties? YES ( ) NO OQ <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 lank(s) pending closure be replaced with aRar3emagrouwl-or underground storage tank(s)? YES[XJ NO[ J <br /> 15. Indicate the responsible party to be billed for additional EHD staff lime 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 M. Alexia Iniciues <br /> Email Address coS c0 arcj ausen.com <br /> Day Phone Number( 425 ) 2 -6222 <br /> 3 <br />