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12. <br />13. <br />14. <br />../ <br />What is the depth to groundwater? <br />Describe the source of information: <br />4 <br />./ r <br />c0";d' fbwJ,J0A <br />Are there any water wells on this parcel or adjacent properties? <br />F WELLS <br />DISTANCE TO TANES(S) <br />Well <br />r <br />ft <br />Well <br />loo ft <br />Irrigation Well <br />fL <br />Monitoring Well <br />fL <br />Other <br />h• <br />YES -WNO[] <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ J NO[ j <br />15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br />per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />Name <br />Mailing Address //- y <br />Day Phone Number ( t71 b ) `i LI n �- <br />Signa a Title <br />EH 23 046 (Revised 08/13/99) Page 6 <br />Date <br />