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12. What is the depth to groundwater'r <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? <br />14. <br />15. <br />TYPE OF WEISS <br />DISTANCE TO TANKS(S) <br />Public Well <br />IN t <br />fL <br />Private Well <br />/rC; + <br />ft <br />Irrigation Well <br />/60+ <br />ft - <br />Monitoring Well <br />D 4- <br />ft. <br />Other <br />bb l <br />fL <br />YES [) NO[ j <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ j NOW <br />Indicate the responsible party to be billed for additional PHS -EBD 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 />R <br />Mailing Address � 7 % 4ve�Yi� S'ZjL"� e�—/4 <br />Day Phone Number ( ) ��� 33!5rb <br />Signature <br />Page 6 <br />Date <br />