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JIM THORPE. OIL. INC 209 768 1851 P. 04 <br /> What Ls the d,sth to ppoundwater', Un/Kit�y y N _ <br /> Describe the c iurce of kiformataa: <br /> Are there an) +rater wells on this parcel or adjacent piropertles? YES NO t] <br /> TIPS OF WELLS , DISTANCE TO TANSS(S) <br /> Public Well <br /> Private Well ft. <br /> Irrigation Well It. <br /> 3fanitor1ng Well rt <br /> Other I R <br /> Will the tank.•; .)pending closure be replaced with an aboveground or underground storage tan3gs)?YES[]NOW." <br /> indicate the ; sporsible party to be billed for additional PES-EHD staff time expended beyond 3 hear minimum permit payment <br /> per tank. If .,is party designated below Is different than the permit applicant,e.g.property owner,the party must acknowledge <br /> this respons4 My for the billing by signature and date below. <br /> Name_ <br /> MaftgAdd;, ss__ <br /> Day Phone Ni.mber ( 7. , /.3,01 <br /> rtle Date <br /> 1011 cj 98' Page 6 <br />