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i <br /> 12. What is the depth to groundwater <br /> 'i <br /> Describe the source of info mallon: f : <br /> CeLI Xri 1 //,2, <br /> 13. Are there any water wells on this parcel or adjacent properties? Y):S NO M <br /> E'YI'E OF WELTS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well ft. <br /> Irrigation Well n• <br /> Monitoring Well ft. <br /> Other ft. <br /> l4. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO <br /> 15. Indicate the responsible party to be billed for additional PIIS-EIID 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 �a-C � st' �f 1•x'1. <br /> © R <br /> Mailing Address /° D' a x /S/Q <br /> Day Phone Number ( -3066 <br /> Signature Date <br /> Page 6 <br />