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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�N0(] <br /> r <br /> OF WELLS DISTANCE TO TANKS(S) <br /> c Well ft. <br /> te Well U ft.ation Well Pt. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES)J NO <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 permit applicant,e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name L 4- Ell I <br /> Mailing Address ,I ?, 1�r�3 -, :r f /�p gr2 M c GQ 93� <br /> Day Phone Number( ) (� L3— Ea <br /> sib <br /> 00 PC2 -/ 9- lid <br /> Signature tie Date <br /> EH 23 046 (Revised 08/13/99) Page 6 <br />