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;'- Wint Is the depth to groundwater? q� ��� ) �1 Cj <br /> Describe the source of Information: _ <br /> oc J c, 0 3 / <br /> �. Are there any water wells on this parcel or, adjacent properties? YES I l NO [yam <br /> TYPE OF WELTS DISTANCE TO TANBS(S) <br /> Public Well - ft. <br /> Private Well n- <br /> irrlgation Well M <br /> Monitoring Well ft. <br /> Other f<. <br /> 14, will the tank(s) pending closure he replaced with on abovtpround or anderrronad storage tank(s)? YES[ J NO[ J <br /> is. Indicate the responsible party to be billed for additional PHS-E" staff time expended beyond 3 hour minhm m <br /> permlt payment per tank. if the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> NameLam✓-14VIO/WC p L 421L P <br /> or <br /> ivfaliing Address72 <br /> Day Phone N7nmber /00 <br /> Signature Date <br /> Page 6 <br />