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12. What is the depth to groundwater9 <br />mat li <br />13. <br />10 <br />15. <br />Describe the source or information: <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 />It. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />YES [ ) NO Jar <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ j N04 <br />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 Aj2 de57r <br />Mailing Address /7ely Z a e- Fors /� GCS_ <br />Day Phone Number <br />Signature <br />Page 6 <br />Date <br />