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tz. n u �depth ro dwate:'! _, <br /> C Ir <br /> 17. Ari tlure any water wcils On this YatnN or adj,ttnt Iro1+"'esE <br /> YES I1 NO� <br /> TYPE OF WII.IS DISTANCE TO WIXSO) <br /> Public Vvi-41 <br /> Priom Weil IL <br /> frt'i;adon well M <br /> Monitoring Well R <br /> pehre t` <br /> A Or uod and stoup,* tattk(s)? YES[ : N0,W <br /> l4• LY it the tankis) pending closure be replaced with as abs end <br /> I:- Indicate the respons.ble party to be tllied ter addinonAl PISS-V= stmt time expended beyond 3 hour <br /> mlai 4`mer, <br /> Perzsic Pa;nnerC per tanL• If the Parry dasieoated below is 11tierenr lban the permit appilean; e.g.p P t'tY <br /> the Party mu <br /> st ack nawledge this responsibility for the billing b;signature and date below. <br /> llailittg Address E 000 �. <br /> Day Phone Number L � <br /> J Date <br /> .4lgt(agtte <br /> Page fi • <br /> TOTAL P.C3 <br /> owl <br /> 01-03-1995 11:12RM P.02 <br />