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:_. What is the depth to groundwater". <br /> Describe the source of information: <br /> Are there any water wells on this parcel or adjacent properties" YES ( ] NO [ ] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well R <br /> Private Well I ft <br /> Irrigation Well ft. <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( ] NO <br /> Indicate the responsible party to be billed for additional PHS-EHD scoff 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 patty must acknowledge this responsibility for the billing by signature and date below. <br /> Name 0 b (d e-tiJ <br /> Mailing Address Si 6—) // C b <br /> Day Phone Number (cD ) y q- q Y <br /> 9 <br /> Si nature Dat <br /> ?aa-- 6 <br />