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12. What is the depth to <br />io - %Z 4 <br />R" <br />14. <br />Ll <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties.' <br />C <br />YES [ 1 NO <br />Will the tank(s) pending closure be replaced with an aboveground o u storage tank(s)'. YES NO <br />15. Indicate the responsible party to be billed for additional PHS -MD staff time e.cpended beyond 3 hour minimum <br />permit payment per tank. If the parry 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`i a-� 4- <br />Mailing Address 2S 8y Zo to <br />Day Phone dumber ( �i ) 3 +� Z ti u u <br />Signature <br />Page 6 <br />)0- lo- �5 <br />Date <br />rrr � <br />C <br />YES [ 1 NO <br />Will the tank(s) pending closure be replaced with an aboveground o u storage tank(s)'. YES NO <br />15. Indicate the responsible party to be billed for additional PHS -MD staff time e.cpended beyond 3 hour minimum <br />permit payment per tank. If the parry 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`i a-� 4- <br />Mailing Address 2S 8y Zo to <br />Day Phone dumber ( �i ) 3 +� Z ti u u <br />Signature <br />Page 6 <br />)0- lo- �5 <br />Date <br />