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12. What is the depth to groundwater? a- <br /> Describe the source of information <br /> 13. Are there any water wells on this parcel or adjacent properties? �r, _ YES ( ] NO ( ] <br /> TYPE OF WELLS DLSTANCE TO TANKS(S) <br /> Public Well It. <br /> Private Well ft <br /> Irrigation Well f[. <br /> Monitoring Well ft. <br /> Other ft. <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES] ] NOX <br /> 15. Indicate the responsible party to be billed for additional PHS-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 /> Name S� M%S26P 4: <br /> Mailing Address R. 1. do-)c 17;) 917 <br /> Day Phone Number ( ok)9 > QSrl - -:�3 `j� ., <br /> S ature Title Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br /> Co 391d -lp1N3WNMJI/1N3 1H9IHM ZST9ZE860ZT 9b:60 866T/6Z/90 <br />