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12. What Is the depth to groundwater? O , <br /> Describe the source of Information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES O NO [1]— <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well R. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well Ct. <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with nn aboveground or underground storage tank(s)? YES( ] NO[ ) r <br /> 15. Indicate the responsible party to be billed for additional PIIS-EIID staff time expended beyond 3 hour minimum <br /> penult payment per took. If the party designated below Is different than the permit applicant, e.g. property owner; <br /> the party must acknowledge this responsibility for the hitting by signature and date below. <br /> Name /11 ( A/J�? L1 l tt ( � �(�l I Z)/Z iklt INS , <br /> Mailing Address h L ( C ��/L :��J�) ✓fL '(- S>4G"'; Tt'n C/a <br /> Day Phone Number (2 <br /> -%3 <br /> Signature Date <br /> i <br /> Page 6 <br />