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L <br /> !2, Mint Is the depth to groutidwaterl Unknown <br /> Describe the source or fnrorma(lont <br /> fIJ. Are there any water welly on this parcel or adjacent properties? YES ( ) NO <br /> LTYPE OF Wi;LLS DISTANCE TO TANKS(S) <br /> Public Well Il. <br /> LPrIVRle well fl. <br /> Irrigntion Well ill. <br /> LMonitoring Well tt. <br /> Other ft. <br /> L <br /> i4. Will 1he lank(s) pending closure be 'repinced with net aboveground or underground storage tank(s)? YES( NO( j <br /> 15. Intllcnle the responsible pnrty to be billed for additional PIIS-EIII) staff(tine expended beyond 3.hour minimum <br /> L permit payment per Intik. Ir the pnrly designated beloir is different ihnn the permit applicant, e.g. property owner, <br /> the party must acknowledge this responsibility for lite b1111iig by signature and date below. <br /> L Name <br /> Molting Address 06 <br /> Ilny Phone Number �� � j t� <br /> Signniure Dale <br /> L <br /> L <br /> L <br /> L <br /> Page G <br /> . . g <br />