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1 <br /> \! J <br /> It. What Is the depth to groundwater? 'A/_ d _ J c) <br /> Describe the source of Inrornnllon: <br /> IJ. Are there any baler wells on tills parcel or ad)ncent properties? <br /> YES [ ) NOA <br /> TYPE,OF WFI.t S fi)ISTANCIFI TO TANKS(S) <br /> Public Well R. <br /> Private Well n. <br /> Irrigation Well R. <br /> i <br /> Monitoring Well R. <br /> Other n. <br /> I.I. WIII the tnnk(s) pending closure be replaced with an aboveground or underground storage lank(s)? YFSt 1 NOA <br /> Is. Indicate the responsible party to be billed for additional PIIS-FIII) staff time expended beyond J hour minimum <br /> permit payment per took. If the party designated below Is different than tiro permit applicant, e.g. properly owner <br /> file party must acknowledge flits responsibility for Ilse billing by signature and dole below. <br /> n I <br /> Name POOL) /`o b <br /> Mailing Address <br /> J J 9vv S /✓i uNSt �yl4n�ee� eA 9s33to <br /> LD �i <br /> Day Phone Numbed <br /> i <br /> Date <br /> gnature i <br /> 1 <br /> i <br /> I <br /> I � <br /> Page 6 <br />