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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 properties? YES [) NO[ ) <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />tt_ <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES 0[ ) <br />15. Indicate the responsible party to be billed for additional PHS•EHD staff 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 billing by signature and date below. <br />Name __!�A i A/ <br />Mailing Address <br />2 <br />Day Phone Number(Z-(^ �33 — .3"� <br />&111 <br />Signature Title <br />/I -/A ' n <br />Date <br />EH 23 046 (Revised 10/19/98) Page 6 <br />