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, <br /> N <br /> 1Z What Is the depth to groundwater? A nnrn x e / b Fal I SG 50 <br /> Describe the source of Information: � <br /> L in es c Foy ' BEIM T� �ro . :�d wafer2 — S�I' InG4 / �19b <br /> 13. Are there any waterwel s on this parcel or adjacent properties? YES [ ] N&( K <br /> TYPE OF WELLS DISTANCE TO TAhES(S� <br /> Public Well rt, <br /> Private Well I tL <br /> Irrigation Well rL <br /> Monitoring Weil iL <br /> Other tL <br /> 14. Will the tanks) pending closure be replaced with an aboveground or underground storage tan*s)T YES[ j N0k <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br /> per tank. If the party designated below is different than the permit app➢canL e.g. property owner, the party most acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name � RniE ,T ci 9 n 0 �no � i Qw �e �2 <br /> MaflingAddress Z '� Fsl� ataso ^,-f Rvn Cjach S / OCKTonJ C [9 95207 <br /> Day Phone Number2( o ) _� �1 C (C <br /> Signature 7itle Date <br /> EH 23 046 (Revised 10/ 19/98) Page 6 <br />