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F" <br />M <br />In <br />19 <br />What is the depth to groundwater? 23 <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WKU.S <br />DISTANCE TO T <br />Public Well <br />ft. <br />Private Well <br />It. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ] NO[ ] t4/A- <br />Indicate the responsible party to be baled for additional PHS-EHD PHS—Estaff time expended beyond 3 hour minimum permit payment <br />per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the baling by signature and date below. <br />Mailing Address + 1 <br />i. ho r y <br />r. -/IA/mi,7 —el 0 <br />Signature Title Date <br />EH 23 046 (Revised 08/13/99) Page 6 <br />