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LLl1F�/Lk7l`1L k�'�: .y7 L97'�4tFJ�4.�� f-1{- I H FLUUk HAUL 1u <br /> 12_ What is the depth to groundwater? JJ Fltfi <br /> pesctlhe the source of Intormatlan_ <br /> 13. Are there any water wells au this YES I] No", <br /> TRE OF WELLS MISTAA'CS TO TANK" <br /> Public Well ft- <br /> Private Well ft. <br /> krigatlon Well 1t <br /> wotrltoring Well fL <br /> Other ft <br /> 14. WW the to s pending closure be replaced with an <br /> � ] aboveground or ttndargtnand storage tartk(s]Y Yg3]]N0K <br /> 15- Indicate the responsible parry to be billed for addldettal PHS-81ID staff time expended beyond 3 hour mlulmam permit payment <br /> per tank. if the party deslguated below 1s different than the permit applicant,e.g.property owner,the patty roust acknowledge <br /> this responsibility for the bluing by slgaatnre and date belays, <br /> yName C�q A vJ t 1 a0l, An r,rl5 TI'tis4 TG 22_ <br /> Mass C}{�p� Pa RT <br /> Day Phone Umber( <br /> 11 -2G'02 <br /> Slgnatare Title Date <br /> &H 23 046(Revised 08/13199) Page 6 <br /> 12/10/02 TUE 09: 43 TTX/RX NO 87091 010 <br />