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12. <br />What is the depth to groundwater? <br />Describe the source of information: <br />_1'/e. rw. <br />i <br />13. Are there any water wells on this parcel or adjacent properties? <br />PIN <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 />3, n F' ° ft. <br />Other <br />ft. <br />YES 0 NO <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[A NO[ 1 <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 owner, <br />the party must acknowledge this responsibility for the billing by signature and date below. <br />Name it /'C f ry /Cy ki-i <br />Mailing Address J �d <br />Day Phone Number ( `/ O <br />/' <br />Signature <br />Page 6 <br />Date <br />