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12. <br />13. <br />0 <br />What is the depth to groundwater? / <br />Describe the source of information: <br />CA1K11t�% oR- n1 t L -,t i . <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft, <br />Private Well, <br />Irrigation Well <br />ft, <br />Monitoring Welli <br />ft. <br />Other <br />ft, <br />YES [ ) NO [.J-" <br />14. Will the tank(s) pending closure be replaced with an aboveground undergrounds rage tank(s)? YES[ ] NO[ J <br />I.S. 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 ✓ofJ vNc r <br />Mailing Address 52S W.SiT'Mp,(p FC(LQ, Uj, 83230 <br />Day Phone Number ( 2,, '1 ) 583- 55 3S <br />r:.� <br />Signature Q Date <br />Page 6 <br />