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12. ��depth <br /> ogroundwater? <br /> hfo� . 2-7 RF4- A-56 . <br /> D � oInformation: <br /> !E&Q.j a wATer tngaag r;ne. w£I�S ®1151TC - <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO[] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> NO Public Well ft. <br /> NQ Private Well ft. <br /> tJQ Irrigation Well it. <br /> Yo Monitoring Well ft. <br /> N(;4 j Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tUMs)?#f0[] <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minim} um 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 C' EG CA& W464 <br /> Q <br /> Mailing Address ^(, (T F <br /> Day Phone Number( 2-o� ) 1 7 8 - 55Q y <br /> e <br /> Signature Title Date <br /> EH 23 046(Revised 10/19/98) Page 6 <br />