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S ITE NUNBER, <br /> 12. What is the depth to groundwater? <br /> LTNIUVOti1TN AT THIS TI1tiIE <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properYES NOties? [ <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($)? YES[ NO[4 <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 /> s responsibility for the billing by signature and date below. <br /> owner, the party must acknowledge thi <br /> Name S'IOCITON PORT DISTRICT <br /> Mailing Address P© BOX 2089, STOCKMN, CA 95201.-2089 <br /> Day Phone Number C <br /> 2019 946-0246 <br /> 1 <br /> ALIST A <br /> ignat}ire / Title Date <br /> EH 23 046 (Revised 9111/96) Page 6 <br />