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�7 L- <br /> 12. What is the depth to groundwater? CICO � 30 G% <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES ( [ NOX <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NOK <br /> 15. 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 /6"2 <br /> Mailing Address 37 �rfTY�� ti cJmUfhy � BCO ew 911�SS3 <br /> Day Phone Number 97 -4i Z 'i�� <br /> /99-7 <br /> P aruI? A�bvs r -z%� <br /> Signature Title Date <br /> EH 23 046 (Revised 7/10/96) Page 6 <br />