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1 <br /> • <br /> 12 What is the depth to groundwater? pip <br /> Describe the source of information <br /> 13 Are there any water wells on this parcel or adjacent properties? YES ] NOV <br /> a <br /> ' TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> ' Private Well ft. <br /> Irrigation Well fL <br /> Monitoring Well ft. <br /> Other ft. <br /> 14 Wlll the tanks)pending closure be replaced with an aboveground or underground storage tanks)?YES(k9 <br /> 15 indicate the responsible art to be billed for additional PDS EHi1 staff time ezpended beyond 3 hour minimum permit payment <br /> p party <br /> per tank if the party designated below is different than the permit applicant,e g property owner,the party must acknowledge <br /> ' this responsiblllty for the billing by signature and date below <br /> Name \y 19R: 1 i i � :Ns <br /> s <br /> % <br /> Mailing Address �u__ � 1 <br /> ' I Day Phone Number( <br /> I leo . <br /> Tilature Title Date <br /> 1 - <br /> T +I <br /> 1 <br /> EH 23 046 (Revised 08113199) Page 6 <br /> i <br />