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015 <br />12. What is the depth to <br />Describe the source of <br />EWA <br />13. Are there any water wells on this parcel or adjacent properties? YES [ ] NO [y]% <br />TYPE OF WELLS I <br />DISTANCE TO TANRS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NOILe <br />15. Indicate the responsible party to be billed for additional PIIS-EIID staff time expended beyond 3 hour minimum <br />permit payment per took. If the pnrty designated below is different than the permit applicant, e.g. property owner, <br />the party must acknowledge this responsibi lily fur the billing by signature and date below. <br />Name Pn 7T Lc l %)- -,� <br />Mailing Address <D ,r7 <br />Day Phone Number ( �(f'v 1��'7 [ --Z144 ( <br />Page 6 <br />Date <br />