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L <br />12. What is the depth to groundwater? ILI, 4 <br />7I( j — <br />Describet e sour a of infor,mmation: <br />t) �c7f �non►T& WC'%I <br />11 <br />13. Are there any water wells on this parcel or adjacent properties? YES .�Y NO [ <br />E OF WMM <br />I DLSTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />75 ft.:L <br />Other <br />ft. <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES} NO[ <br />15. 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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name <br />Mailing Address <br />Day Phone Number (qff, ) % <br />Signature <br />Page 6 <br />GQt w 2-7, (4i3 <br />Date <br />