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12. <br />13. <br />14. <br />15. <br />0M <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 />ft. <br />Private Well <br />ft. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />..7r ft <br />Other <br />ft. <br />M <br />YES g NO [] <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage <br />tank(s)? YES[ ] NO)( <br />Indicate the responsible party to be billed for additional E 1D 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 />XI)Ry Fhone-W,mbc <br />EH 23 046 (Revisedl0/16/03) Page 6 <br />M <br />