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12. <br />13. <br />14. <br />U <br />What is the depth to groundwater? <br />Describe the source of information: <br />501 <br />Are there any water wells on this parcel or adjacent properties? <br />1] <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 />YES [ ) NO X <br />Will the tank(s) pending closure be replaced with an aboveground o ndergroand orage tank(s)? YESM NO[ j <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 <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name JA4 MA4Y tAr-IL 24rTK — <br />Mailing Address �� 05 NA�� a 'z ' CA 'q5 -Z,0( <br />Day Phone Number ( ZC>q <br />tur Title Date <br />EH 23 046 (Revised 7/10/96) Page 6 <br />