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I?- What is the depth to groundwater? L\n r\) U \ n� <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YESA NO[] <br /> c <br /> lY <br /> TYPE OF WELLS DISTANCE TO TANKS(S) ///X Public Well ft. <br /> Private Well ft. <br /> Irrigation Well M <br /> Monitoring Well ft. <br /> Other R <br /> 14 Will the tanks)pending closure be replaced with an aboyeground or underground storage tank(s)?YES[I NO[I T�1// 1 <br /> 15. Indicate the responsible party to be billed for additional PHS-EED staff time expended beyond 3 hoar minimum permit payment <br /> per tank. If the party designated below is different than the permit appllcaai.e.g.property owner,the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> Name—� 1lt� -�!' A [, �-- - 7'N\ 7 E� C-\ P.7 \ NC <br /> Mailing Address?�P p S o N TU S t b Ly <br /> Day Phone Number 9( 7S S - z 44 4 <br /> �a 1-:2,U 1�C i T'fl�I�� RCtli <br /> Signature TitleDate <br /> EH 23 046 (Revised 10119/98) Page 6 <br />