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• • <br /> 12. What is the depth to groundwater? t)o+ Kne a A <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO(] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> i <br /> Public Well tL <br /> Private Well I rt- <br /> Irrigation <br /> LIrrigation Well tL <br /> Monitoring Well tL <br /> Other ft <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 permit payment <br /> per tank. If the party designated below Is different than the permit appOcant e.g.property owner,the party must acknowledge <br /> this responsibility for the billing <br /> si by signature and date below. <br /> Name12CiI1Pl // �] /( <br /> �L[ �A <br /> Mailing Address I6ib �iCffISIOP IGU mtmyl C q�;SC I/u <br /> Day Phone Number( 116 ) qX -713� <br /> - 6 741 <br /> Siguature Title Date <br /> EH 23 046 (Revised 10/19/98) Page 6 <br />