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STKN . SER .STAT . EQUIP . CO TEt "l,o . Ju 1 -'11 ,97 15 :22 No . 007 P .03Os <br /> � f <br /> ! <br /> 12. What Is the depth to groundwater? <br /> De sc "be th source of information: 4 <br /> t`1 Com+ <br /> 13. Are there any water wells on this parcel or adjacent properties? ;s YES { NO rf, <br /> h <br /> e <br /> "k <br /> 7Ebe <br /> WELLS DLSTA14CE TO TANKSM E� <br /> Well <br /> .; <br /> eltft• <br /> Well ft rL <br /> k <br /> NOX14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YESI 1 <br /> 15. Indicate the responsible party <br /> to be billed for additional PHS-EHDrstaff time expended beyond 3 bour 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 blllin� by signature and date below. <br /> k <br /> k <br /> Name <br /> Mailing Address ' <br /> s <br /> Day Phone Number <br /> - =Z,7 <br /> Signature Title Date <br /> .f <br /> 'i <br /> z <br /> �3 <br /> I <br /> EH 23 046 (Revised 9111/96) page 6 <br />