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13. <br />14. <br />15. <br />What is the depth to groundwater! , <br />i>/lJUNOwIATr/i IS A��OyiMATt�/ /� �C7S <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WEI.IS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />It. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />rt. <br />KeCa <br />YES [ ) NO <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NOw <br />Indicate the responsible party to be billed for additional PHS-EIID 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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name TEi F_ 6 -Fry 0 F M,461y , ,4r7 -N : /6:JVL d�R.AIA <br />Mailing Address SZD rRAC Y 11VA 71UCV C4, <br />-?-Oct�l) u <br />OI s��b <br />Day Phone Number (Oct ) — /qZ0 <br />Signature <br />Page 6 <br />/0/V <br />Date <br />