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12. <br />13. <br />14. <br />What is the depth to groundwater' <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WENS <br />DISTANCE TO TANS.S(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />M <br />YES [I NO �G <br />Will the tank(s) pending closure be replaced with an aboveground • undergroun storage tank(s)'. YES NO[ <br />1�. 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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name -1 �-; 4- kq <br />Mailing Address 2 iS c� Svn ri �) ✓� S `^ ` te- Zo lv <br />Day Phone Number (q I L ) L, 3 C3 2. H u" <br />Signature <br />Page 6 <br />10- tri- 6,S <br />Date <br />