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12. What is the depth to groundwater? <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent proper-ties? YES NO <br /> TYPEOFWELLS DISTANCE TO TANKS(S) <br /> Public Well ft, <br /> Private Well <br /> Irrigation Well <br /> Monitoring Well ft. <br /> Other <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage tank(s)? YES[ NO[ <br /> T <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 Address A-L A,,A (2 4 t- CL"' C,3 <br /> Day Phone Number 3c -r- kic'� <br /> %-� <br /> L) IS <br /> Signature Title Date <br /> EH 23 046 (Revised 07/31/08) <br />