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0 0 <br />12. What is the depth to groundwater? 12C <br />1 <br />Describe the source of <br />13. Are there any water wells on this parcel or adjacent properties? YES [I NO K <br />TYPE OF WELIS <br />DISTANCE TO TANKS(S) <br />Public Well <br />rt <br />Private Well <br />it <br />Irrigation Well <br />ft <br />Monitoring Well <br />It. <br />Other <br />It. <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ I NOt4 <br />15. Indicate the responsible party to be billed for additional PHS -EH D 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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name A <br />_� - '7,' (L\ El 0�5 <br />Mailing Address <br />Day Phone Number <br />1-30 q3 <br />Signatu Date <br />Page 6 <br />