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1 <br />12. What is the depth to groundwater? <br />G1.lil �l�IOlr�//l <br />13. <br />14. <br />15. <br />Describe the source of Information: <br />Are there any water wells on this parcel or adjacent properties? <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />rt. <br />Irrigation Well <br />ft. <br />Monitoring Well <br />ft. <br />Other <br />ft. <br />YES [) NO <br />Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[ ) NO.K <br />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 z4Q �eS7iG <br />Mailing Address <br />rd <br />Day Phone Number ( i 14 ) 9�'Y-136 lam% <br />Signature <br />Page 6 <br />Date <br />r. , <br />