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.. .. <br /> 12. What is the depth to groundwater? VaKt)aja <br /> Describe the source of information: <br /> 13. Are there any water wells on this parcel or adjacent properties? YES ( f NO�Q <br /> TYPE OF WELLS DISTANCE TO TANKS(S) <br /> Public Well ft. <br /> Private Well M <br /> Irrigation Well ft_ <br /> Monitoring Well lY_ <br /> Other ft <br /> 14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YESJQ NO( I <br /> I5. 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 &VC'pyt--',/� <br /> Mailing Address �Ut:LG VOC,4 )JiJAG (r�76y?,i P3S O LZA550.-� RD ` � /a2 q <br /> ) 3)!0 <br /> Day Phone Number <br /> �-a • / G� i l✓clams,/ A)JckF S-� '"sic 3TC S S� <br /> Signature Titic Date <br /> EH 23 046 (Revised 9/11/96) Page 6 <br />