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May - 23 . 2003 2: 53PM GI 0 r Environmental No.0371 P . 5 <br /> 12. What is the depth to groundwater? �t •4- <br /> Describe the source of Information: . <br /> 1$. Are there any water wells an this parcel or adjacent properties? ygg Bot� <br /> TM OF WME DISTME TO T <br /> Public Well It. <br /> Private Well ft. <br /> Irrigation Well fk <br /> Monitoring wen !t Ov1• ${ - <br /> { Other , <br /> 14. Will the s)pending closure be replaced wn an Ibmvinmd or wdergroud storage s)?nW RO[I <br /> 25. Indicate the responsible Wty to be billed for additiODRI P B staff time expended beyond S hour mWmtm permit paymot <br /> per tank If the pargt designated below is different the permit applicant,e.g.property owner,the Pam MM admewledge <br /> this responsibility for the billing by signatue and date below, <br /> Rama ' c+Gl r F Prov, lrv. w4cJcc.t?S Tc.. <br /> MaMag ddress!��-(lc� — <br /> Day Phone Number(_ `/-Z-S' <br /> I " <br /> Signature Title Date <br /> , <br /> 1 <br /> I <br /> EH 23 046(Revised 08/13/99) <br /> Paze 6 <br />