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12 <br />13. <br />14 <br />15 <br />What is the depth to groundwater?�/� <br />Describe the source of information: <br />14 - 6 a6"taI . - <br />Are there any water wells on this parcel or adjacent properties.? q Ow Oc✓ AI YES [ I NO [ I <br />TYPE OF WELLS <br />I DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YESWO( <br />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 party designated below is different than the permit applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name 6(AW1 %l 2Z1e"if/fll�14 CV -)Pe -- <br />Mailing Address �D/ C. <br />Day Phone Number -70e <br />&--4i I i Z%P L'LhZr �) <br />Signature Title <br />EH 23 046 (Revised 9/11/96) Page 6 <br />a-/47 <br />Date <br />