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12. What is the depth to groundwater? /20 <br /> Describe the ource of'nfo ation: <br /> Lt-es O� !f4Ue,f ae�7(t -fn [tat er lu Grells - SIS taq I1b .3 <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 with an aboveground or underground storage tank(s)? YES[ ] NO,Kj <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name �Drf���r C111L��f�1 <br /> Mailing Address CIO -Ke�lYlct iA. �5Oy( Fe), Fo%4 $770-,& Mod eJ6 r (—A 153.T-7 <br /> Day Phone Number ( Z05 ) 5Z14 —q(.-71 <br /> Signature Title Date <br /> EH 23 046 (Revised 7/10/96) Page 6 <br />