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s <br /> 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [] NO <br /> TYPE OF WRUS DISTANCE TO TANKSM <br /> Public Well ft. <br /> Private Well 1t. <br /> 1 <br /> Irrigation Well it <br /> Moultorlag Well ft. <br /> Other n <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or nndemnund storage tank(s)?YE O[[ <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 applicant,e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name it <br /> Mailing Address 2 (if�(} -2 'Gk- C v., J t7n %7 2�9 <br /> Day Phone Number( ®-1 ) +6-j ! <br /> e <br /> { <br /> i <br /> 1 <br /> EH 23 046(Revised 08/13/99) Page 6 <br />