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12. <br />13. <br />r <br />14. <br />15. <br />What is the depth to groundwater? <br />Describe the source of information: <br />SITE NTJIMBER 9 <br />UNjUJ0JVN AT THIS TIME <br />Are there any water wells on this parcel or adjacent properties". <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) 1 <br />ft. <br />ft. <br />90theri <br />ft. <br />ft. <br />ft. <br />YES f I NO M <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES( j NO[4 <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum <br />designated below is different than the permit applicant, e.g. property <br />permit payment per tank. If the party <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name STOCKTON PORT DISTRICT <br />Mailing Address <br />PO BOX 2059, STOCKTON, CA 95201-2059 <br />209 946-0246 <br />Day Phone Number L!�� <br />] ALIST (d <br />Si�znatur <br />Title Date <br />EH 23 046 (Revised 9111196) <br />Paye 6 <br />