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v <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: / n <br /> cod W1c.14S <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [ ] NO (� <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced will an abov un r 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 <br /> permit payment per tank. If the party designated below is different than the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Tl <br /> a <br /> Mailing Address <br /> Day Phone Number ( I ) 464Z <br /> L�� 1*1 i�F1t7T _ I I q <br /> Signature Date <br /> Page 6 <br />