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12/111/'117111 11y:313 2094603433 hlF IH YLULRK <br /> M What lsthe depth togtnuddtratarr pvt 25' <br /> Describe tha source of information: <br /> 6aGaa Da.lt�„vq I.Jri6sl+c <br /> 13. Are there any water wells oa this Daccal or adJaceot prepetttesy YES )) NO LT <br /> TIME OP WMI A►ATANCS TO TAMDM <br /> Public well fc <br /> Private Well ft <br /> _ Iffigation Wen ft <br /> Monitoring Well ft. <br /> other ft <br /> 14. Wil the taWgs)pending closure be replaced with an aboveground a nodetgrennd storage tan143)Y YLq)NO[i <br /> 15- indicate the responsible party to be billed for additional V99-M staff time expanded bayand 3 hour minimum permit payment <br /> _ per tank. it the party designated below is different than the permit appOcanC e.g.property owner,the party must aclmomledge <br /> Ods responsibility for the haling by slgnahue and data below. <br /> Name Ski/, it 1 <br /> MaWagAddress yoaS Porr Cbt�aan ftglnwaLlj ane00-0 T452- 7 <br /> Day Phone Number 4( 2-55 210 3 <br /> T1aS� tNlana�e.r 1[26-0 ti <br /> Signature Title Date <br /> EN 73 046(Revised 08/13/99) Page 6 <br /> 12/10/02 TUE 09:43 [TX/RX NO 87091 X005 <br />