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12. What is the depth to groundwater? • OEM <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YESX NO f <br /> TYPE OF WELLS USTANCE TO TANICS(S) <br /> Public Well ft <br /> Private Well oft <br /> Irrigation Well ft <br /> Monitoring Well ft <br /> Other ft <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES( NO�q <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 parry designated below is different than the permit applicant, e.g. property <br /> owner, the parry must <br /> ttacknowledge <br /> `this <br /> responsibility �fo-r�thebillingby signature and date below. <br /> Name �' CS F," JGtav L C6Ga',l�t, ��� )_ <br /> Mailing Address ��6D W1 u.J/`�� tp'-[) Rte � -T a&z�m .11 �—Lt 9-53 v <br /> Day Phone Number ( au 8316-3388 <br /> Signature Title Date <br /> F <br /> EH 23 046 (Revised 7/10/96) Page 6 <br />