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l5 <br />12. What is the depth to groundwater? <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? <br />..i <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />A <br />ft. <br />Private Well <br />7S <br />ft. <br />Irrigation Well <br />,i%A <br />ft. <br />Monitoring Well <br />D <br />ft. <br />Other <br />141A <br />ft. <br />YES `[< NO I I <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES;XNOj 1 <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 this responsibility for the billing by signature and date below. <br />Name _ 11joer z- / :OLZ- J1l <br />Mailing Address <br />Day Phone Number �OZ e3 S— — Z7Jr� <br />EH 23 046 (Revised 9/11/96) Page 6 <br />Date <br />