Laserfiche WebLink
FBRMES. INSURRNCE 209 399 5421 F.82 <br /> `e <br /> i2. what it the dD tF grw+nJ.rntcl: <br /> D's�t©�u£BLt,tLPr'/f 'fU..Wkf9—(A) Gt/bS — <br /> V. Are there any water wells on this parcel or adjacent properties? YJ NU l I <br /> TYPE ON wFUS DISTANCE TO TANXS(S) <br /> Public Well <br /> Private well 6o to <br /> Irrigation well M <br /> Njonitoring well <br /> • Q(11Er �' <br /> 14. Will the tank(s) pending closure be replaced with an Wxnvgrootsd or underground storage t2ak(s)4 YES(I NO(I <br /> 13. Indicate the responsible patty to be billed for additional PHS-EBD staff time•pended beyond3 hour minimum <br /> permit payment per tank. If the party designated below is different than the permit appliont,e.g.property owner, <br /> the party must scknowledae this responsibility ror the billing by signature and date below. <br /> Nance W t t 1 L!a nI t=t. >o <br /> Mailing Address 17881 Glenwood Drive, Manteca, CA 95336 <br /> Day Phone Number ( 209 } 823-4930 - <br /> . �,iarf2 //-/ - <br /> Signature Data <br /> Page 6 <br /> TOTFL P.OZ <br /> 11-01-1994 04:46PM 209 599 5421 P•02 <br />