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0 • <br />12. What is the depth to groundwater? u Y) L110 LOA) <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />YES [I NO <br />rjA <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[ ] <br />15. Indicate the responsi arty to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br />permit paym per taa f the party designated below is different than the permit applicant, e.g. property <br />owner, t acknowledge this responsibility for the billing by signature and date below. <br />Name 0—a i 140 <br />ahona-1 Guam <br />0 <br />Mailing Address o' &X 0249101 —SaChaVNe-n-r , Cq 9--�8.2-k <br />Day Phone Number ( 91L <br />Signature <br />Title <br />EH 23 046 (Revised 9111196) Page 6 <br />Date <br />