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J1N. TH0RPE. 0IL . INC 209 368 1851 P. 03 <br /> What is the del, ItoKioundwater?-- L_c.-ytw.SGW,J <br /> Pasclibo tba sc :se of informadon: <br /> Ard there any I, ,ter wells on this parcel or adjacent properties? YES NO J J <br /> TYPE Op WELLS DISTANCE TO TANKS(S) <br /> Public Wall tt <br /> Private Well It <br /> irrlgadon WeU— IL <br /> Monitoring Well fL <br /> Other It <br /> Will tha tank(;, pendi ag closure be replaced witb an aboveground or underground storage taak(s)?Yq J NO(J <br /> indleata the r ponstble party to be billed for additional P8&EBD staff time expended beyond 3 hour minimum permit Payment <br /> per tank. It til Pariy designated below Is dlfreeent than the permit appilcant,e.g.property owner,the party meat aoknewledge <br /> this re3pouslh ity fa:the billing by signature and date below. <br /> NatneGene Wa110m..-- <br /> MaillogAddr. 3 __ 11292, Nor-$:h Alni na Rn�rl <br /> Day Phone Nn rber i'..2 0 9-- 1.-.---, 948-0792 <br /> -_---_--.--•_.-.__--- <br /> '•11l04ture _ Tide Data <br /> I ;? tY161Revise( 0'1',,98) Page 6 <br />