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%001 ./ <br /> 12. What is the depth to groundwater? C�o, 5 r l <br /> Describe the source of Information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YESX NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public WeD It. <br /> Private Well ft. <br /> irrigation Well ft. <br /> Monitoring Well S ft. <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 applicant,e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name i ,�A IP4ACt - AVN 7 1� KS�-\nC\ N7kEcz� lM <br /> Mailing Address ?, �3 Po 5 t -z-, L\I-1�,* e,6(a R PINI( \mh Fix-sLo\I A '-2 S-)4?- <br /> Day Phone Number( ��( . 1 3� - �>-4� 4 <br /> j VW I 6A-4X — P R C) r`_C i 1-^ AM P\ <br /> oeeDate' <br /> C t � <br /> MpatTit► Date <br /> EH 23 046 (Revised 10/19/98) Page 6 <br />