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11, What is the depth to groundwater? <br /> Describe the source Of InNrmatiant , <br /> 13. Are there $MY water wells an this parcel or adjacent properlles7 <br /> 'I• pg OF R'EL.t.S DIBTANCR TO TCAMM(S) <br /> Public Well <br /> private Well It' <br /> Irrigation Well n• -- <br /> Monitoring Well n. <br /> Other ft' <br /> ld, Will the tank(s) pending closure be replaced with an aborepvund or underground storO&C tank(8)7 YES[ I Na; <br /> Indicate the responsible party to be hilted [or additional PHS-EUD staff time expended beyond 3•h4 r minimn <br /> 15. Err <br /> permit payment per tank. 1[the part) designated below 1s different than the permit applicant, e.g. p p rt7 <br /> titT for the bllllna by algnatgre end dale below. <br /> the party must acknowledge thls responsibt <br /> Name <br /> Mailing Address <br /> Dar phone Number t C ) <br /> Date - <br /> Signature <br />