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to roundwate� <br /> � Wheat U the depth a / <br /> Desetlbe <br /> The eource 01'IRNMRtlurtt <br /> Nv <br /> water wells nn this ercel or adjacent prapertles7 4 <br /> t3+ ,Are there Ani p <br /> Tvo>r�vFt. A WgrANCE TO TANKt3M � <br /> Pubiic Wtll 1 <br /> � I <br /> prl,rate well —�-�-- <br /> Irdemlon well ' <br /> monlierine Well <br /> other <br /> laced wlih an a ngronnd or undergrumAd elorage tonk(s)7 <br /> R will the tank(e) pending closure be replaced <br /> ib <br /> Indlaete the t�esponslble party to be billed ror additlonal pll5- HUI lhdnIng tthe expended <br /> lt app!Rnt* e.8 propei r erf <br /> peat q m stlacknowi ackper Wilt,nthe party owledge responal6!tTted for below Is the bili! a by elgnato►re and date below. ; <br /> r <br /> ,� � ,.s ,r <br /> Name + L' / <br /> Malling Address <br /> DAr Phone Number ( ) <br /> Dale <br /> Signature <br />