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%Ir v <br /> 12. What is the depth to groundwater? <br /> Describe the source of Information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [1 NO 1.1 <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well It. <br /> Private Well R <br /> Irrigation Well It. <br /> Monitoring Well It. <br /> Other <br /> It. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YESES NOI 1 <br /> 15. Indicate the responsible party to be billed for additional PHS•EHD staff time Mended beyond 3 hour minimum permit payment <br /> per tank. If the party designated below Is different than the permit applicant,e.g.property owner.the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name L-a .; B 01 - <br /> Mailing Address !ice 38 r+4.e�e+�• 9:�� <br /> Day Phone Number <br /> N <br /> L� D. r TIt te 9 4 <br /> Signature TIUe Date <br /> Ell 23 046 (Revised 10/19/98) Page 6 <br />