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000279 <br /> 12. What is the depth to groundwater'' <br /> AMMMiMaXkhQAZ— <br /> Describe the source of information: ^ Citw �t1[1® �rr1Y¢rd!ndwatei trtOrlltDrin¢®tertaoram <br /> t ro nies? YES [X I NO[ l <br /> 13. Are there any water wells on this parcel or adjacentp pe <br /> rPnivate, <br /> PE OF WELLS DISTANCE TO TANK S <br /> lic Well <br /> Well <br /> ation Wellnitorin Well roximatel 250 ft. <br /> Outer M water a roximatel 4150 ft <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?[X] NO ( I <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit <br /> payment per tank. If the party designated below is different than the permit applicant,e.g.property owner,the party must <br /> acknowledge his responsibility for the billing by signature and date below. <br /> Name v i <br /> Mailing Address - -v-- - fl�, o,._gog r jvjj e%m rA 9454® --- <br /> Day Phone Number 510 1423:6U7 <br /> Signature Date <br /> 6 <br />