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��—iu-17�y r�rs-�rsrri rKui i TO 14252518782 P.05 <br /> . I <br /> 12. Wtthre <br /> e de to / <br /> grcuadwater? <br /> i} he source of ft formadom <br /> 3. Any WaterWeIIs on tfzts parcel or aQacaut Properties? uS i) NO <br /> H' <br /> TYPE OF WELLS DlS"rm(;E To TMRS) <br /> Pubne Weil ft. <br /> Private Wen ft_ <br /> Ir ariau Wen fL <br /> Monitoring Wefl fz <br /> Other it <br /> Will the tanlg8)O@udlng dosure be replaced with au above9=d or and <br /> ertound storage tanks)?YfU[j <br /> fuikatA the responsMe Party to be billed for additional PR54M staff do expended b"uIId 3 hour nanimm <br /> lithe Party desi�na below is diflereat dtaa the penWt lit awe g <br /> res nsffi ty for tbn property owner,the patty mflst acn�oiede <br /> hilHng by signatzu'e and date below. <br /> Name /LL /2Cp lLo _119 75 <br /> ddress <br /> Day PI, a Nttmber( /�a <br /> anztue ate <br /> 1 <br /> 23 046 (Rev' d 10/19/98) Page 6 <br />