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s <br /> 12. What is the 9denth to groundwater? <br /> Cosy ' ?) 0 a <br /> Describe the source of information: <br /> "� <),7k4 IN) Ed P5" c t✓ozkx; - >=c oon f Tt7o� Mss f7L f ' 9S <br /> 13. Are there any water wells on this parcel or adjacent properties? '4K1Kvt,-7" YES NO [ ] <br /> TYPE OF RAS DLSIANCE TO TANBS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well fl <br /> Other R <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground s orage tank". YESNO( <br /> 15. Indicate the responsible parry to be billed for additional PIIS-EAD stair 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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> Name Prc In t� f4`'Yi I G,4{]7 <br /> Mailing Address <br /> Day Phone Number ( ) <br /> Signature Date <br /> Page 6 <br />