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12 What Is the depth to groundwater? Co 5 r i <br /> Describe the source of information: <br /> czRuunn �"\ a : EZ t-4(IM1 7 NCS REV-z VRi <br /> 13. Are there any water wells on this passel or adjacent properties? YESX NO(] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well S fG <br /> Other ft. <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES[]NO[] TU/141 <br /> 15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minim®permit payment <br /> per tank It 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 7 47 E S N C <br /> Mailing Address apo 'E� t 'L� vJ ?.6(o iRAtii NAO <br /> Day Phone Number( <br /> 4 g, A( R a 1� <br /> Signature Tltl j Date <br /> EH 23 046 (Revised 10/19/98) Page 6 <br />