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whet b !ia depJt tri ylrottniwater'. _ � <br /> r,,ur *e thi source of tet ormatlon _ - <br /> 13. Are there any wattr wells!.n- this Farre} or adjacent properties? YES ( J NO I J <br /> TYF E OF t'c'1 LL.3 DISTANCE TO TA`7KS(f7 Y <br /> Public Wcjl.'.' <br /> Private Well !G _ <br /> irri;,atlan Well rt - <br /> Monitorl,tg Well R <br /> 14. `n7,1 the :ark�sJ ;e^�1In�doaure ?x rcy,ac.i ':•I:h an aiKivegx,cao or gn3rZruQ.xd stcrge tank(s)? IIEZZI I NO( 1 <br /> IS. ndtxte the taslonslbtr party to ,rt 'nlIA for adtiitiottal PHS-EIED staff time expended bryorcd 3 hour tsh:t uct <br /> permtt p4yraeot -er teak, It the (*arty deslgnafed below is different than he permit Dpp cant, ag property ctiwner, <br /> the party must sckrowl�'.ge this ,espottslh.tlty for the I+itling by slgnatute and date below. <br /> Mame <br /> intatll g Addreas ? J © 0 C'S AJ rt �A,, 1=�nR r <br /> - Day Fhorte ' • x. 0 <br /> `,er ( _______ <br /> S ;f.;re - Data <br />