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I::. <br />13. <br />14. <br />14 <br />11 <br />What is the depth togroundwater? <br />a, <br />Describe the source of information: <br />Are there anv water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />I DISTANCE TO TANKS(S) <br />Public Well <br />I ft. <br />Private Well <br />ft. <br />Irritation 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 or linde=und-storage tank(s)? YESX NO[ <br />V <br />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 parry designated below is different than the permit applicant, e.g. property <br />tp tp <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />Name "i <br />Mailing Address <br />Day Phone Number ( 0 *), q7 7 - 36 qJ <br />_Aoq ) 94.3 <br />/5 <br />Signature Title <br />EH 23 046 (Revised 9/11196) Pagre 6 <br />Date <br />