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12. What is the depth to groundwater? U K(4- <br /> Describe <br /> LDescribe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES [I NO [] <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well 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)? <br /> YES[] NOD( <br /> 15. Indicate the responsible party to be billed for additional EHD staff time expended beyond 3 hour <br /> minimum permit payment per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by <br /> signature and date below. <br /> Name (A/ A 1.T- +" F.ht a e-F- 2 r.t C TiK C - <br /> Mailing AddressI? p o X O Z f Lll S A-e a CA �?S-6 4 ( <br /> Day Phone Number & ) 3 Uzi flSZ <br /> ` A+K tL '& c & LO <br /> Signature Title Date / <br /> EH 23 046 (Revised 11/21/06) 6 <br />