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1.2. What is the depth to groundwater? <br />Describe the source of information: <br />7:. Are there any water wells on this parcel or adjacent properties? UV) YI ®t) h YES (] NON] <br />TYPE OF WELLS <br />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 />1.4. Will the tank(s) pending closure be replaced with an aboveground or underground storage <br />tank(s)? YES[ ] NO[ ] L?,a V L} <br />15. Indicate the responsible party to be billed for additional 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 <br />Mailing Address _ <br />Day Phone Number <br />Signature <br />Title <br />FH 23 046 (Revised 10/16/03) Page 6 <br />Date <br />