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/ � f <br /> 12. What is the depth to groundwater? L <br /> Describe the source o: informa il <br /> n lU'tn &AJ � <br /> 13. Are there any water wells on this parcel or adjacent properties? YES ] ] NO <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <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[ ] NOX <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 <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name 4, , N)0 <br /> Mailing Address 2,< � <br /> Day Phone Numbers -ZS <br /> t <br /> Sig tune Titl Date <br /> EH 23 046 (Revised 9111196) Page 6 <br />