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12. What is the depth to groundwater/ <br /> Describe the source of information: <br /> YES Q NO[) <br /> 13. Are there any water wells on this parcel or adjacent properties? <br /> TYPE OF WELLS DISTANCE TO TANES(S) <br /> Public Well tt' <br /> Private Well tt' <br /> Irrigation Well tt" <br /> Monitoring Well tt' <br /> Other <br /> tt. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES(]NQ <br /> to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br /> 15. indicate the responsible party must acknowledge <br /> per tank. If the party designated below isdifferentnd date belo .permit applicant,e.g.property owner,the party <br /> this responsibility for the billing by signature <br /> Name L <br /> Mailing Address 7 <br /> Day Phone Nmnber L <br /> �1U <br /> P <br /> tie Date <br /> Signature <br /> EH 23 046 (Revised 08/13/99) <br /> Page 6 <br />