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1 , <br /> 11 '"at 1.1 the depth to groundwater? <br /> 10 to 15 fair <br /> nascrlbe the tourte of information: <br />' previcus work in the area, <br />' IJ. Are there any rater wells on tills parcel or adjacent properties? YM { ] NO �(] <br />' TYPE OF WhuS dLITANCE TO TAMO(S) <br /> Public Well It, <br />' Private Wel! R <br /> lrrigadon Well R <br />' k Innitoring Well , <br /> Other F- ft. <br /> I <br /> I <br /> td Wttl the tnnk(a) pending closure be replactd with alt aboreroand or underground storage tank($)? YMJ ] NO( <br /> 15. Indicate the responsible parry to be billed for additional PHS-EHD staff time expended b"Ond 3 hoar winitttutn <br /> permit parmetit per tank. If the party deslgneted below Is difrerent than the permit appllcsta4 e.g. prop" owner, <br /> thA party must acknowledge (his responslbliiry for the billing by signature and ditto below. <br />' Name Fi,,erstdc Ce'fPr :� Cb. - Attent#gn ; Mike Selxas <br /> Dialling Address P.O. Box 158, Oro Grande , CA 92368 <br /> IDar Phone Number { 619 � 2245-5321 (Re Pur chdsa Order No. R1. 201958) <br /> zz <br /> Signature Bate <br /> I <br /> Face 6 <br />