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12. What Is the depth to groundwater? '6 rtr 26 PT_ <br /> Describe the source of Information: <br /> 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 fL <br /> Private Well ft <br /> Irrigation Well h. <br /> Monitoring Well ft. <br /> Other It. <br /> i <br /> 14. WIll the tanks)pending closure be replaced with an aboveground or underground storage tank(s)?YES[]NO[[ <br /> i <br /> 15. Indicate the responsible party to be billed for additional PHS EHD staff time expended beyond 3 hour minimum permit payment <br /> per tank. If the party designated below is different than the permlt applicant,e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> 1 <br /> Name nn I I 1 ^ <br /> Mailing Address X005 c�1� 1Porr te_agp 4Nq twee- g C.bl1G0Y-D gN5�2t] <br /> Day Phone Number( 266 2103 <br /> i <br /> i 'rRSk yl/ltznc(�e r I (-26-D -2- <br /> Signature <br /> Signature Title Date <br /> 1 <br /> i <br /> EH 23 046(Revised 08/13/99) Page 6 <br />