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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 WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft <br /> Irrigation Well ft <br /> Monitoring Well ft <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ j NOX <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br /> permit payment per tank. If the party designated below is different than the permit applicant, e.g. property <br /> owner, the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name .eO71 <br /> Ipl <br /> Mailing Address /S/.$ S i c <br /> Day Phone Number ( <br /> I6l f 2 <br /> Signature Title G Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />