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.r <br /> 12. What is the depth to groundwater? <br /> �• 5 b�? �ow Gr'o.r�P, <br /> Describe the source of informatio1n�: A,t / <br /> �15o i\ O�y�CI pJ`oJ nG'We C/' ASSGSSYM Y`P./)2 /J lre d �v �01 (4z. rA .V0 Wl 1J <br /> �n vac r <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [ ] NO KI <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well it. <br /> Private Well it. <br /> Irrigation Well it. <br /> Monitoring Well it <br /> Other it. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NOLO}' <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br /> </�` <br /> permit payment per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge thisresponsibilityfor the billing by signature and date below. <br /> Name _ L � �6 ��1ti 11 ( � '✓1r71 aLQ �r r �r� �� Vl n <br /> Mailing Address �b00 C. Cr \Nin i PG"( Q- 5' k '' CG vvk0,\ CIy3-53 <br /> Day Phone Number ( 5 ID <br /> ��0 Q '�AI <br /> Signature Date <br /> Page 6 <br />