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12. What is the depth to groundwater? <br />13. <br />14. <br />15. <br />Describe the source or information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WENS <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 />YES [) NOA <br />Will the tank(s) pending closure be replaced will an aboveground r underground storage tank(s)? YESKI NO[ I <br />Indicate the responsible party to be billed for additional PIIS-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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name <br />T <br />AJ <br />Mailing Address 1 (D Q0, -i -77q% +" t( ES 11 0 q3 7a-7 <br />Day Phone Number ( 309 ) Q S 6 L4 6 0 U <br />Signature <br />Page 6 <br />a -a3 -5 <br />Date <br />