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M i <br /> 12. What is the depth to groundwater? <br /> Describe the source of informati9p: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [ ] NO [ J <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well V ft. <br /> Irrigation Well ft. <br /> Monitoring WeleaO <br /> ft. a,2�'�GF��-�1,0,60 <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ J NO <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 /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name <br /> Mailing Address <br /> Day Phone Number ( ) <br /> Signature Title Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />