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i • <br /> 12. What Is the depth to groundwater? -+rL <br /> Describe the source of information: <br /> 13. Are there any water wells an this parcel or adjacent properties? YES ]] NOW <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well it. <br /> Monitoring well ft< <br /> Other ft. <br /> I <br /> 14. win the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES(]NOK <br /> 15. Indicate the responsible party to be billed for additional PHSWEHD 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 �j 114 1,) Ly L)I fi bYi V),) 07 1 + 7y r-p <br /> Mailing address (400 5- T Ck Ceo- L? 0,[��w ct viti (�p()G00.p 2 (D <br /> Day Phone Number( 123 112 p'jam T <br /> I <br /> Signature Title Date <br /> t <br /> I <br /> : <br /> I <br /> EH 23 046(Revised 08113199) Page 6 <br />