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t <br />12. What is the depth to groundwater? A'V'&'. IAAOA"c <br />Describe the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? <br />J I <br />W <br />UMK� <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES P( NOI I <br />15. Indicate the responsible party to be billed for additional PHS-Estaff 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 IZ -"e�" V �- -P I f, +r- b W I— <br />Mailing Address FV ^VX >xC'- <br />Day Phone Number ( 7 07 14 & 6-16� t <br />Signature Title <br />A <br />EH 23 046 (Revised 9/11/96) <br />Page 6 <br />Date <br />Public Well <br />Private Well <br />Irrigation Well <br />Monitoring Well <br />UMK� <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES P( NOI I <br />15. Indicate the responsible party to be billed for additional PHS-Estaff 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 IZ -"e�" V �- -P I f, +r- b W I— <br />Mailing Address FV ^VX >xC'- <br />Day Phone Number ( 7 07 14 & 6-16� t <br />Signature Title <br />A <br />EH 23 046 (Revised 9/11/96) <br />Page 6 <br />Date <br />