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12. <br />13 <br />14. <br />15. <br />What is the depth to groundwater? <br />Describe the source of information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />Private Well <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />YESA NO [ ] <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? <br />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 />Name51 <br />Mailing Address <br />r <br />Day Phone Number E3 el 26 7 <br />CDS Pyr✓ <br />3 73' <br />SignatCue Title <br />EH 23 046 (Revised 07/31/08) 6 <br />Datq <br />] NOX <br />