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12. <br />13. <br />I 14 <br />15. <br />What is the depth to groundwater? <br />Describe the source of information; <br />SITE NUMBER 10 <br />1jN1Cg0JVN AT THIS TIME <br />Are there any water wells on this parcel or adjacent properties? <br />YEs [ ] NO ja111 <br />Will the tank(s) pending closure be replaced with an aboveground or andergmund storage tanks)". YES[ j NON <br />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 STOCKTON PORT DISTRICT <br />Mailing Address PO BOX 2089, STOCKTON, CA 95201.-2089 <br />209 946-0246 <br />Day Phone Number <br />1ALIST-0 <br />1C� Ct <br />Signature <br />�L---'Title <br />Date <br />EH 23 046 (Revised 9111196) <br />Page 6 <br />