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13. Arc there OM water wells oo this parcel Of adjaoetn PLOPeRie37 YES [.1 NO <br /> TYPE Or WELLS DUTANCE TO TANKSM <br /> Public Well R <br /> erivax Well fl <br /> irrigation Well fL <br /> Monitoring Well ft. <br /> Other R <br /> 14. W0l the tank(s)pending closure be replaced with so Aboveground or underground storage tank(s)? YESI I Nb[I O <br /> 15. Indicate the responsible party to be billed for additional EHD staff time expended beyond 3 hour minimum <br /> permit payment per tank. If the party designated brlow is different than the permit applicant,e,&property <br /> owner,the party must atiimowledIR this responsibility for the billing by signore and date below. <br /> Name� <br /> Mailing Addres8!ZQ r7 E, C �•n <br /> r <br /> Day Phone Number —6Y( <br /> �tilY O <br /> signature Title --� Date <br /> E 23 046 (Revised IM1107) 6 <br /> zoo[n <br />