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�I V <br /> 12. What is the depth to groundwater <br /> I I /o <br /> Describe the source of Information: <br /> GGIcNr � b�t/L/LI( �fiUdatXEd6. GLA.QEA <br /> —Tv �r/n,QD f <br /> 13. Are there any water wells on this parcel or adjacent properties? <br /> YES [ ] NO� <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well It. <br /> Private Well R <br /> Irrigation Well It <br /> Monitoring Well (t. <br /> Other It. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ) NO <br /> 15. 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_ l NE CZT %SAG / A7TN ' x'12 fJ9l1L ��i2M/� <br /> Mailing Address <br /> Day Phone Number <br /> �/(/�/I/�—C3�� 10121/9 3 <br /> Signature <br /> Date <br /> Page 6 <br />