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r ' <br /> \/ <br /> 12. What is the depth to groundwater?_a1VA,460L2/Y <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES NO[] <br /> TYPE OF WELLS DISTANCE <br /> TO TANKS(S) <br /> Public Well 5(p / It <br /> Private Well It <br /> irrigation We ft <br /> Monitoring Wen ft <br /> Other It <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)?YES[]NDO( <br /> 15. Indicate the responsible party to be baled for addltlonal PHS-EED staff time expended beyond 3 hour minimum permit payment <br /> per tank. If the party designated below is different than the permit appncant,e.g.property owner,the party must acknowledge <br /> this responsibility for the Ming by signature and date below. / <br /> Name ,C G L.nuOS [►�A�(/S7/GLLr <br /> MalD 'ngAddress // zO J <br /> Day Phone Number( �2 3 <br /> Signature tle Date <br /> EH 23 046(Revised 08113/99) Page 0 <br />