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i <br />• 12. What is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES C ] NO C I <br /> TYPE OF WMIS DISTANCE TO TANKS(S) <br /> Public Well ft- <br /> Private Well ft. <br /> Irrigation Well ft. <br /> Monitoring Well �- ft. <br /> Other ft. <br /> 14 Will the tank(s) pending closure be replaced with an aboveground 4underground torage tank(s)? YES NO[ ] <br /> 15. 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 owner, <br /> the party must acknowledge this responsibility for the billing by signature and date below. <br /> NameJ L j RPS�M A L �— 1Q C <br /> Mailing Address Z <br /> kJ -IDA eD� % LD C4 3z3fl <br /> Day Phone Number RZ2 3 <br /> Signa Date <br /> i <br /> Page 6 <br />