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12. What Is the depth to groundwater? <br /> Des��tr'ttbe the source of tufo}�tation: <br /> f1)im�i rfn�Tf a+r! 7 l7 <br /> 13• Are there any water wells on this parcel or adjacent properties? YES [[ MIX <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> /� <br /> Public Well tL <br /> Private Well h, <br /> Irrigation Well K, , <br /> Monitoring Well n, <br /> Other ft <br /> i <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES[i NO[j <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum 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 <br /> below. <br /> Nama�('I 7�T t �yc <br /> Melling Address '&Z F 00- Z <br /> IDay Phone Number J-02 ,93?—A7,:V <br /> ! <br /> Signature Mu <br /> Pill` 111 <br /> lure �e Data <br /> I <br /> I <br /> EH 23 046(Revised 08113199) <br /> Page 6 <br />