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S <br /> 12. What is the depth to groundwater? �� �� 3 /_ Ogg <br /> _U- <br /> Describe the source of information: <br /> l�`sh�w (✓moi{/(.E'y ;�jf�T77{ /�! <br /> 13. Are there any water wells on this parcel or adjacent properties? YES ] NO [ I <br /> TYPE OF WELLS I DISTANCE TO TANSS(S) <br /> 17r5r � de L/AM <br /> Public Well it <br /> Private Well ft <br /> Irrigation Well ft <br /> Monitoring Well ft- <br /> Other g (I ft Z Y w f S <br /> VaJ 7,Q,9• / <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[/] <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <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 this responsibility for the billing by signature and date below. <br /> v <br /> Name AN, e t C l <br /> Mailing Address 52177 LkLL(L o U - �1i90fdYra <br /> Day Phone Number (D ) LI 4� - �L4(� y <br /> Signature Date <br /> Page 6 <br />