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WED 1?:44 p I <br />P ST OiL 9 <br />1 63T240T9 <br />P'.0 <br />�Z. 'what is the t#epLh t0 <br />j - groundwater? <br />Describe the source of information: <br />j ('vt �� v <br />i <br />13, Are there any waters wells on this parcel or adjacent Frc�perties? <br />! i W rTNO <br />I � ' <br />7'E OF WEBS Dcr <br />TO TANKS(S) <br />Public well <br />It. <br />I Private well <br />11 ,1 ft, <br />Irrigation Well <br />Monitoring Well <br />It. <br />Other <br />I I <br />14. <br />Will the lank() PendingClosure I . <br />ore be replaced wills an :Faprt%t,Q„n4 or underground storage tank(s)? YES[ j NO j-r <br />Indicate the rtSponSlble party to be billed for Addlli0n2l pl,S�EIID staff time <br />emit payment per tank II the pnrty'drslgnnted below is dlffererBf 4ta:sn the nded beyond 3 hour minimum <br />the party must acknowledge this r'e•`pr�nsibiPlty tar the :,tiling b t Permit o lican <br />y s gn;olure and date i elo a-g. property owner, <br />Nome � <br />Mailing Address 1 <br />Day Phone Number ? -S373— <br />Page <br />S373— <br />Page 6 <br />