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13. Are there any water wells on this parcel or adjacent properties? YES [] NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irri ation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[)NO[g <br /> 15. Indicate the responsible party to be billed for additional 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 <br /> owner,the party must acknowledge this responsibility for the billing by signature and date below. <br /> , <br /> Name <br /> Mailing Address 13101 <br /> Day PhoneNumber(`Z« ) ��S �� 6o <br /> to <br /> Siinatd4 Title Date <br /> EH 23 046 (Revised 12/31/07) <br />