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11-30-1999 1 0:40AM F(R0'4 Pr' i <br /> M What is the depth to groundwater? <br /> Describe the sourer,of information: <br /> 13. Are there any water wells on this parcel cr adjacent properties? YES [1 NO[) <br /> TYPE OF WAS DISTANCE TO TANKS) _ <br /> abliv Well ft. <br /> Private Well ft <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other M - <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage taak(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 <br /> Mallintg Address 2e� <br /> Day Phone Munber <br /> 3i a e tie !Pate <br /> EH 23 046(Revised 08/13/911)) Page 6 i <br /> i <br />