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P groundwater? VA)e1�V) <br /> 12. What is the depth to � <br /> Describe the source of Information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] 11 V�( <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well fL <br /> Private Well ft. <br /> Irrigation Well fL <br /> Monitoring Well ft. <br /> Other fL <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES[I Nq <br /> 15. Indicate the responsible party to be baled 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 appllcank e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name G/ <br /> Mailing Address /✓, �G �Q�(/ft/�/(� S�©c%7.J �r9- 9 �a o <br /> Day Phone Number( <br /> Gtr Gl�1 �/-OS' <br /> S ature ltle Date <br /> EH 23 046 (Revised 10/19/98) Page 6 <br />