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`. <br />13. Are there any water wells on this parcel or adjacent properties? YES NO f ) <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />u� <br />Private Well <br />DX. 20011• <br />Irrigation Well <br />ft. <br />L)w <br />Monito' Well <br />ft. <br />�iry <br />Other <br />fl. <br />Uro <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ I NOX <br />is. Indicate the responsible party to be billed for additional ELID staff time expended beyond 3 hour minimum <br />permit payment per tank. f 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 />h4aifirig hddreseaa t 14` { i_TQ?e' 4i (h�3�Lf�� <br />Day Phone Number <br />-__S ZIv C GB <br />Signature Title Date <br />EH 23 046 (Revised 12/31/09) 6 <br />