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12. What is the )e th to gro, inriwnter7 <br />Describc the source of information: <br />13. Are there any water wells on this parcel or adjacent properties? YES NO ❑ <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />00 <br />ft. <br />ft. <br />Dr <br />ft. <br />Private Welltg <br />Irrigation Well <br />Monitoring Weilft. <br />fOC� <br />eo <br />6�A u <br />Other OL.S;t�}e <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground <br />storage tank(s)? YES ❑ NO*' <br />15. Indicate the responsible party to be billed for additional 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 <br />Mailing <br />Address . D. <br />Day Phone -7 <br />No. <br />1 <br />1� <br />Signature Title Date <br />EH 23 046 (Revised 10/16/03) Page 7 <br />