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12. What is the depth to groundwater? L)AJK lOW1r <br />Describe the source of Information: <br />13. Are there any water wells on this parcel or adjacent properties? YES [ 1 NO[ 1 <br />TYPE OF WELLS <br />DISTANCE TO TANKS(S) <br />Public Well <br />ft. <br />Private Well <br />ft. <br />igation Well <br />fLnitoring <br />Well <br />rOth <br />tL <br />er <br />rL <br />14. Will the tank(s) pending closure be replaced with an aboveground or underground storage tank(s)? YES[] NO[ 1 <br />15. Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond 3 hour minimum permit payment <br />per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. <br />Name NQ/✓1'4�(yvl <br />LO�t$iZU�i1P'✓! <br />--- — <br />Mailing Address <br />i �O f�Ci E <br />re A 10 Rt2 <br />(�i/l�e L <br />Day Phone Number lACaq ) q4 3 —7S)0SPj <br />v T ( ✓fie' ¢,i �Q.na �a � 4 <br />Signature Title Date <br />EH 23 046 (Revised 10/19/98) Page 6 <br />