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ti <br /> 12 What is the depth to groundwater? Unknown by contractor. ti-3n <br /> Descrlb the source of Informatlon: J <br /> �:,�L� <br /> 13. Are there any water wells on this parcel or adjacent properties? YES () NO[}� <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well M <br /> Private Well I fL <br /> Irrigatlon Well tL <br /> Monitoring Well fL <br /> Other fL <br /> 14. Will the tank(s)pending closure be replaced with an aboveground or underground storage LaWgs)?YESM NO[1 <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—NO—&LHp -4 2 c � �-/V f 7� <br /> () S�2C91 C �N C' <br /> Mailing Address 10 q a �S P Q�b <br /> Day Phone Number <br /> Signature Title Date <br /> EH 1.3 046 (Revised 10/19/98) Page 6 <br />