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DEC- 6-95 WED 14:39 KLEINFELDER FAX NO 2WN8Ub21 r. 1ileu <br /> 4410 <br /> 1: What is the depth to gmundwate;' <br /> Describe the source of information: <br /> 1., Ate there an, water wells on this parcel or adjacent properties". YES ( 1 NO <br /> TYPE OF WELLS DfSTAVCF TO TANKS(S) <br /> Public Weil <br /> Private Well IL <br /> Irrigation Well rt. <br /> Monitoring Well ft_ <br /> Other <br /> t replaced with an abov and or underground storage tank(s)? YES( j Nt� <br /> L.L. Will .he tank(s) pending closure be p egro <br /> 15. Indicate the responsible pally to be billed Car additional PHS•EHD s=LT time expended beyond 3 hour minimum <br /> permit payment per tank. If the patty designated below is different than the permit appilmnt, e.g. property owner, <br /> the parry must acknowledge this responsibility for the hilling by signature and dace below. <br /> Same 'PA 1A <br /> Mailing AddressZjQ�� ✓ ���! (�"�� � � �S r �J � <br /> Day Phone Number `( e 6 <br /> Uate <br /> signature <br /> Page 6 <br />