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12. <br />13. <br />14. <br />15. <br />What is the depth to groundwater? AI &� 55 ' <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? YES [I NOI <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ j NO/ <br />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 ]ails & Kz L'' "i"J r,� h <br />Mailing Address :3 6 Dlt yt msi �� k� i 641 15 ZO <br />Day Phone Number <br />Signature Title <br />EH 23 046 (Revised 9/11/96) Page 6 <br />R -a3 41" <br />Date <br />