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[z, <br />13. <br />14. <br />v <br />What Is the depth to groundwater? <br />�ye-11 <br />Describe the source of Informations <br />Are <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANIM(S) <br />Pnblle wen <br />n• <br />Private Well <br />M <br />Irrigation Well <br />It. <br />Monitoring Well <br />ft. <br />Other <br />�• <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ I NO[ j <br />15. Indicate the responsible party to be billed for additional PIIS-EIID 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 />Name <br />C <br />Mniling Address <br />Day Phone Number <br />Sigrenture <br />Page 6 <br />d -may -moi' <br />Date <br />